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Airplane ownership CV19


bonal

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Hang in there ILC...

1) It is true... all opinions are not equally valid...

2) It is also true... that everyone's opinions do count...

3) In a place that is as small as MS... it isn’t very hard to get to know all the members, over time...

4) We also get to know how they type vs. how they speak in person... when we see each other at fly-ins...

5) Speaking allows for some expression, that just doesn’t come out in typing...

6) My typing has come further than my speaking has... a very long recovery process...

7) We learn so much from one another... whether it is the type of work they do, or area they live in, or where they are on the time line of life...

8) Everyone has some important knowledge to share...

9) It is best we keep everyone involved... it takes some extra effort... and somebody will try their best to include people...

10) It is great to have experts around here... and people that are physically in different areas... you never know who can help you with your next project...   some MSer knew more about Firebird ignition systems than me... five lines of typing was very helpful.... Another was in Amsterdam... a place I used to visit frequently...

11) When looking for an epidemiologist, I am probably looking forward to five lines of typing from someone... who has time and can be pleasant in a public environment...

12) It is tough to have credentials and be pleasant at the same time.... can take decades for some...

13) In the end... we’re all in this together... this virus isn’t picking any favorites... or maybe it is...

Stay in touch... even if it is the click of a like button... Stay positive!

Best regards,

-a-

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@bonal, I feel your pain. Tough choices right now. Reopen too soon or too much at once and we still get a huge peak and the last month was essentially wasted but the damage done. Reopen too late and the economy is devastated, people lose their jobs and homelessness and crime skyrocket as well as all the other harms resulting from poverty.

If we had implemented better testing capacity (like S Korea) then perhaps we could make more strategic decisions about what to open when, but without a reliable way to measure the outcome we’re interested in we are stuck with making “educated guesses.” As you know, one of the hallmarks of the scientific method is that these change as we get more information. I trust the guy that admits he has new information and changes his estimates accordingly more than the one who sticks to his original predictions despite evidence to the contrary.

Tough choices and hopefully the smartest people in the room are the ones making them. Certainly seems better than the alternative.

Not to brighten your day even more, but domestic violence and child abuse have also jumped dramatically during this “stay at home” time. I have unfortunately seen this first hand. 

If you have any solutions I’m happy to hear them because I certainly don’t have the answer. I do hope you understand the underlying issues involved, however, and see that this is a highly complicated high-stakes decision and most likely not a political power grab that’s being undertaken for personal gain.

https://apple.news/A0lbgreVIS56KVbfmrAdwgQ

Edited by ilovecornfields
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"Reopen too soon or too much at once and we still get a huge peak and the last month was essentially wasted [bold added by me] but the damage done" 

I disagree. Your implicit premise is that our levels of suppression can actually halt spread and ultimately eradicate the virus from a population.  I strongly suspect that is not possible - this virus spreads so efficiently (unlike it's closest highly lethal kin SARS) that it will emerge rapidly after any relaxation in suppression. Real world evidence? Look at what happened in Japan and what is happening in Singapore right now - they acted more strongly and earlier than we ever could.   If I am right (still hope I'm not but that hope is fading), the clear implication would be that roughly the same total number infections are needed for this epidemic to go away no matter what strategy you take to mitigate it.  Unless you get an effective vaccine, which is 1 year away if we are lucky and could prove to be MUCH further off. 

"If we had implemented better testing capacity (like S Korea) then perhaps we could make more strategic decisions about what to open when"

We will see who is better off in the end - Milan and NYC, or Seoul. If my logic above is correct, the prediction would be the former. Herd immunity is a more subtle concept than suggested by its portrayal in the lay media, but it is a very relevant one .

"without a reliable way to measure the outcome we’re interested in we are stuck with making “educated guesses.”" 

What specific testing capacity are you hoping for? How would that measure the outcome we are interested in? What is that outcome?  In my view, most of the people screaming for more testing don't really understand what makes for a good test or how to implement one effectively in a particular clinical scenario. 

I'm a 4th rate pilot, but I do have a little knowledge in this particular area...

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5 hours ago, DXB said:

"Reopen too soon or too much at once and we still get a huge peak and the last month was essentially wasted [bold added by me] but the damage done" 

I disagree. Your implicit premise is that our levels of suppression can actually halt spread and ultimately eradicate the virus from a population.  I strongly suspect that is not possible - this virus spreads so efficiently (unlike it's closest highly lethal kin SARS) that it will emerge rapidly after any relaxation in suppression. Real world evidence? Look at what happened in Japan and what is happening in Singapore right now - they acted more strongly and earlier than we ever could.   If I am right (still hope I'm not but that hope is fading), the clear implication would be that roughly the same total number infections are needed for this epidemic to go away no matter what strategy you take to mitigate it.  Unless you get an effective vaccine, which is 1 year away if we are lucky and could prove to be MUCH further off. 

If there is no treatment than you are correct but if there is an effective treatment, you are dead wrong. The entire point of “flattening the curve” is NOT to reduce the overall NUMBER of infections but to decrease the AMPLITUDE of the peak so that hospital systems are not overwhelmed when all the infections happen at once. For your statement to be true the survival would have to be equal at home and in the hospital and this is not the case. 80% mortality on the vent in the ICU is better than 100% mortality needing a vent at home.

"If we had implemented better testing capacity (like S Korea) then perhaps we could make more strategic decisions about what to open when"

We will see who is better off in the end - Milan and NYC, or Seoul. If my logic above is correct, the prediction would be the former. Herd immunity is a more subtle concept than suggested by its portrayal in the lay media, but it is a very relevant one .

I’m not sure how to respond to that. Yes, we’ll see.

Quote

"without a reliable way to measure the outcome we’re interested in we are stuck with making “educated guesses.”" 

What specific testing capacity are you hoping for? How would that measure the outcome we are interested in? What is that outcome?  In my view, most of the people screaming for more testing don't really understand what makes for a good test or how to implement one effectively in a particular clinical scenario. 

I'm a 4th rate pilot, but I do have a little knowledge in this particular area...

By a “reliable” test I’m referring to a test with high sensitivity and specificity both for acute testing and for antibody testing. If the nasopharyngeal PCR could achieve anywhere near the >95% sensitivity and specificity that they claim and we had a reliable antibody test then you would have a good way to see who hasn’t been exposed, who has active infection and who had previous infection. 
Negative PCR/neg IgM/IgG - no exposure

Positive PCR/pos IgM/neg IgG - active infection

Negative PCR/neg IgM/pos IgG - prior infection

Yes, I understand likelihood ratios, pre-test probabilities and post-test probabilities quite well and I also understand that the presence of IgG antibodies does not guarantee a certain degree or duration of immunity, but having this information is certainly more useful than having nothing at all.

In your expertise, what would you suggest as a better alternative? 

 

Edited by ilovecornfields
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From an article published in the New England Journal of Medicine...

If one assumes that the number of asymptomatic or minimally symptomatic cases is several times as high as the number of reported cases, the case fatality rate may be considerably less than 1%. This suggests that the overall clinical consequences of Covid-19 may ultimately be more akin to those of a severe seasonal influenza (which has a case fatality rate of approximately 0.1%) or a pandemic influenza (similar to those in 1957 and 1968) rather than a disease similar to SARS or MERS, which have had case fatality rates of 9 to 10% and 36%, respectively.2

https://www.nejm.org/doi/full/10.1056/NEJMe2002387

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19 minutes ago, David_H said:

From an article published in the New England Journal of Medicine...

If one assumes that the number of asymptomatic or minimally symptomatic cases is several times as high as the number of reported cases, the case fatality rate may be considerably less than 1%. This suggests that the overall clinical consequences of Covid-19 may ultimately be more akin to those of a severe seasonal influenza (which has a case fatality rate of approximately 0.1%) or a pandemic influenza (similar to those in 1957 and 1968) rather than a disease similar to SARS or MERS, which have had case fatality rates of 9 to 10% and 36%, respectively.2

https://www.nejm.org/doi/full/10.1056/NEJMe2002387

Correct. We don’t have an accurate count of the number of deaths and we don’t have an accuracy count of the number of infections (current or past) so the case fatality rate is a moving target. 
 

To paraphrase one of my heroes “You fight a pandemic with the information you have, not with the information you wish you had.” As I’ve mentioned a few times - you make your best guess with the information you have at your disposal at the time and adjust accordingly as you have new information. 

Edited by ilovecornfields
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15 hours ago, ilovecornfields said:

@Hyett6420, you just don’t get it. I had to take a break from this place due to all the clueless people taking about how “educated” they were... I don’t know if you heard, but our Fearless Leader, a genius among geniuses, just announced a cutting edge treatment a few days ago that will eradicate the disease! Can’t wait for him to try it out

P.S. - Don’t ingest or inject Lysol or Clorox like Trump suggested. You’ll die

12 hours ago, ilovecornfields said:

...then having some random person on the internet who calls themselves “educated” suggest that they know more about it than you do and then vigorously try to defend their ignorance while repeating political taking points.

 

image.jpeg.7b1a5a0773cc018607dce5bdc525360e.jpeg

just sayin’

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8 hours ago, David_H said:

From an article published in the New England Journal of Medicine...

If one assumes that the number of asymptomatic or minimally symptomatic cases is several times as high as the number of reported cases, the case fatality rate may be considerably less than 1%. This suggests that the overall clinical consequences of Covid-19 may ultimately be more akin to those of a severe seasonal influenza (which has a case fatality rate of approximately 0.1%) or a pandemic influenza (similar to those in 1957 and 1968) rather than a disease similar to SARS or MERS, which have had case fatality rates of 9 to 10% and 36%, respectively.2

https://www.nejm.org/doi/full/10.1056/NEJMe2002387

It would be really really nice if CFR turns out to be 0.1%, implying the  asymptomatic pool was greater than tenfold the symptomatic one - we could back off suppressive strategies much more quickly.  The compelling evidence just isn't there yet -  hence the softly worded editorial.  There are multiple reasons why we don't have the information, but the most prominent one is the severe limitations of interpreting positive serologic tests, and it is going to be tought to get to a point where we have reliable info.

In the long term, I suspect the virus will evolve into one that has a CFR like seasonal flu - the immune selective pressure will force it to choose to maintain  transmissibility over pathogenicity.

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5 hours ago, ilovecornfields said:

By a “reliable” test I’m referring to a test with high sensitivity and specificity both for acute testing and for antibody testing. If the nasopharyngeal PCR could achieve anywhere near the >95% sensitivity and specificity that they claim and we had a reliable antibody test then you would have a good way to see who hasn’t been exposed, who has active infection and who had previous infection. 
Negative PCR/neg IgM/IgG - no exposure

Positive PCR/pos IgM/neg IgG - active infection

Negative PCR/neg IgM/pos IgG - prior infection

Yes, I understand likelihood ratios, pre-test probabilities and post-test probabilities quite well and I also understand that the presence of IgG antibodies does not guarantee a certain degree or duration of immunity, but having this information is certainly more useful than having nothing at all.

In your expertise, what would you suggest as a better alternative? 

 

Quantifying any rare condition in a population with a lab test accurately (here presence coronavirus IgM/IgG) is very difficult as you are aware - that 95% sensitivity/specificity for a lateral flow immunoassay will identify 5% positive in a totally virus-naive population. And the better more quantitative test (ELISA) can't be scaled up to millions of people easily. So we will only have good serologic data when there are truly lots of antibody-positive people in a population - I bet you most populations in the US will not have a large previously infected fraction at the present time.  There are also many assumptions behind your 3 bin categorization scheme that will prevent its practical application - either guiding suppressive measures for a population or restricting activity for individuals (setting aside the important individual rights can of worms for now).  Accurately defining active infection in an asymptomatic low prevalence population with a PCR test has all the same quantitative pitfalls and some others.  An NP swab PCR test's negative predictive value  drops off steadily and dramatically from the moment of symptom onset - there are tons of people in the hospital with a negative test who obviously have the disease based on chest CT.  At an individual level, it is really only reliable right at symptom onset.   Another major pitfall: it's not just that the antibody itself isn't fully protective of permanently protective, it may not be the protective mechanism at all and not even correlate with the presence of the protective mechanism (cell mediated immunity).  This is not a trivial, low probability consideration - the vaccine development efforts for SARS directed at humoral immunity weren't all that effective, which is pretty ominous in my view.  The WHO keeps bringing this issue up during the present rush to worldwide serologic testing and talk of "immunity passports" based on the test. But that point is not an easy one to convey, and constantly leads to headlines like "No evidence infection confers immunity," which is dead wrong - some degree of protection after infection is very likely even if it is far from perfect. The point is there is a serious and legitimate concern that antibodies are not an effective window either into prior infection or effective immunity.  The implications for vaccine development are also profound - we may end up needing a recombinant live virus like the VSV-based one that ultimately showed efficacy for Ebola but has a less favorable side effect profile. That will take much longer and be much harder to implement widely.

In the near future, the only sensible alternative to is to calibrate policy based on hospitalizations and deaths in a population with only limited social restrictions. Specifically creating massive war-time effort of expanding critical care capacity and tailoring social measures not with the intent of stopping spread but maintaining a steady, nonexponential sweep through the population.  That approach also allows a partial economic recovery along with a much more rapid trajectory to this epidemic burning out.  Nothing else makes sense if we will have to absorb approximately the same number of deaths anyway.

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3 minutes ago, DXB said:

Quantifying any rare condition in a population with a lab test accurately (here presence coronavirus IgM/IgG) is very difficult as you are aware - that 95% sensitivity/specificity for a lateral flow immunoassay will identify 5% positive in a totally virus-naive population. And the better more quantitative test (ELISA) can't be scaled up to millions of people easily. So we will only have good serologic data when there are truly lots of antibody-positive people in a population - I bet you most populations in the US will not have a large previously infected fraction at the present time.  There are also many assumptions behind your 3 bin categorization scheme that will prevent its practical application - either guiding suppressive measures for a population or restricting activity for individuals (setting aside the important individual rights can of worms for now).  Accurately defining active infection in an asymptomatic low prevalence population with a PCR test has all the same quantitative pitfalls and some others.  An NP swab PCR test's negative predictive value  drops off steadily and dramatically from the moment of symptom onset - there are tons of people in the hospital with a negative test who obviously have the disease based on chest CT.  At an individual level, it is really only reliable right at symptom onset.   Another major pitfall: it's not just that the antibody itself isn't fully protective of permanently protective, it may not be the protective mechanism at all and not even correlate with the presence of the protective mechanism (cell mediated immunity).  This is not a trivial, low probability consideration - the vaccine development efforts for SARS directed at humoral immunity weren't all that effective, which is pretty ominous in my view.  The WHO keeps bringing this issue up during the present rush to worldwide serologic testing and talk of "immunity passports" based on the test. But that point is not an easy one to convey, and constantly leads to headlines like "No evidence infection confers immunity," which is dead wrong - some degree of protection after infection is very likely even if it is far from perfect. The point is there is a serious and legitimate concern that antibodies are not an effective window either into prior infection or effective immunity.  The implications for vaccine development are also profound - we may end up needing a recombinant live virus like the VSV-based one that ultimately showed efficacy for Ebola but has a less favorable side effect profile. That will take much longer and be much harder to implement widely.

In the near future, the only sensible alternative to is to calibrate policy based on hospitalizations and deaths in a population with only limited social restrictions. Specifically creating massive war-time effort of expanding critical care capacity and tailoring social measures not with the intent of stopping spread but maintaining a steady, nonexponential sweep through the population.  That approach also allows a partial economic recovery along with a much more rapid trajectory to this epidemic burning out.  Nothing else makes sense if we will have to absorb approximately the same number of deaths anyway.

Hear, hear. 

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8 hours ago, ilovecornfields said:

"Reopen too soon or too much at once and we still get a huge peak and the last month was essentially wasted [bold added by me] but the damage done" 

I disagree. Your implicit premise is that our levels of suppression can actually halt spread and ultimately eradicate the virus from a population.  I strongly suspect that is not possible - this virus spreads so efficiently (unlike it's closest highly lethal kin SARS) that it will emerge rapidly after any relaxation in suppression. Real world evidence? Look at what happened in Japan and what is happening in Singapore right now - they acted more strongly and earlier than we ever could.   If I am right (still hope I'm not but that hope is fading), the clear implication would be that roughly the same total number infections are needed for this epidemic to go away no matter what strategy you take to mitigate it.  Unless you get an effective vaccine, which is 1 year away if we are lucky and could prove to be MUCH further off. 

If there is no treatment than you are correct but if there is an effective treatment, you are dead wrong.  The entire point of “flattening the curve” is NOT to reduce the overall NUMBER of infections but to decrease the AMPLITUDE of the peak so that hospital systems are not overwhelmed when all the infections happen at once. For your statement to be true the survival would have to be equal at home and in the hospital and this is not the case. 80% mortality on the vent in the ICU is better than 100% mortality needing a vent at home.

 

"If there is no treatment than you are correct but if there is an effective treatment, you are dead wrong."

A word on hope for any truly effective therapy emerging quickly (hydroxychloroquine, ivermectin, remdesivir, favipiravir, tocilizumab, whatever): Shots taken at viruses using even the most promising drugs usually don’t hit their mark – they are elusive targets for small molecule therapies. Look at the enormous sustained efforts and dead ends at every step that were required for other viruses. Those steps involve developing basic mechanistic insights, identifying lead compounds to target those mechanisms, showing drug efficacy in preclinical models, and ultimately progressing through clinical trials. As a result we now have good drugs for herpes viruses, Hep C and HIV, but only a marginally effective one for any RNA respiratory virus (i.e. influenza). Should we really think it's going to be easier for SARS-CoV2 than it's been for influenza?

The point is that its likely to take many shots on goal over years to score a clinically useful agent for COVID19. The clinical data supporting efficacy of any drug for SARS-CoV2 is incredibly weak - merely hypothesis generating.  So right now, that effort should be spread across a variety of existing and developmental drug classes without excess focus on any single agent - a very slow process by its very nature.  But the risk of not doing it this way is the diversion of resources from the broad-based trial and error approach needed to establish an effective therapy as well as the futility of haphazard off label use (e.g. hydroxychloroquine).  

"The entire point of “flattening the curve” is NOT to reduce the overall NUMBER of infections but to decrease the AMPLITUDE of the peak so that hospital systems are not overwhelmed when all the infections happen at once. For your statement to be true the survival would have to be equal at home and in the hospital and this is not the case. 80% mortality on the vent in the ICU is better than 100% mortality needing a vent at home."

I've never questioned that it's important to at least try to match the rate of people becoming critically ill to ICU capacity, but slowing disease spread is only one side of the equation. Expanding capacity is the other, and we have made moves in that direction during this brief interlude of suppression, but they are not enough.  Given the natural interia and pain involved, we will only see the full level of resourcefulness, creativity, and political will needed to expand capacity when the worst problem is back in our face.  The resulting expansion of care capacity can maintain most of the survival benefit once the pressure is really on.  And the increased case volume and clinical experience will also resolve some of the raging debates in the critical care community about COVID19 (e.g. should all severely hypoxic cases be treated like ARDS). That will ultimately improve clinical outcomes, not worsen them.    

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@DXB. Your solution seems much simpler. Don’t try to test people, just grow ventilators, hospitals and intensivisits.

I appreciate your suggestions, But I think we can agree to disagree.

Your assumptions regarding the fallacy of testing depend on the test having a low pre-test probability to begin with (and therefore a low PPV when positive). Unless you test a large number of people you have NO idea what the baseline prevalence of disease is. 0.2%, 2%, 20%? You don’t know, and therefore you can’t accurately calculate those values.

No test is perfect and no one will argue that. But they have a place in this outbreak and dismissing testing because it has its limitations seems like a huge mistake. If you use mortality as a proxy (which some have suggested) then your “most current” data will lag 15-40 days (average time from exposure to death) so by the time you see the effect of your interventions you’re weeks-month “behind the curve” so to speak. How far do you move down that exponential growth curve in a month? Then another 14-40 days to see how your next change plays out? No thanks! I’ll take my imperfect tests that can start to show trends in a few days than my also imperfect mortality data that’s putting me weeks behind what’s going on.

And by “effective treatment” I didn’t mean a miracle cure like what’s touted on television,  but even the things we’re currently doing that have already reduced mortality for critically ill patients (supportive  care, anticoagulation) and again point out that as long as we have ANY effect on the disease course (which we do) then your assumption is wrong. Your statement depended on mortality at home being equal to hospital mortality and it never has been. 
 

I don’t see how you have ANY chance of “marching patients to capacity” (which I think is you acknowledging the above statement) without extensive testing  I’ll take imperfect data that I can view trends in today vs. slightly better data that’s several weeks old anytime I’m dealing with exponential growth. I think it would be a mistake not to.

Edited by ilovecornfields
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On 4/23/2020 at 7:43 PM, Eight8Victor said:

Have any of you business owners gotten any of the PPP money? None of my customers (small business owners) have received anything. I applied three weeks ago and nothing. Just curious.

 

On 4/23/2020 at 9:28 PM, Ross Taylor said:

Not us. And to my knowledge, no business in Flagstaff has (I've asked our local Small Business Development Council, too). But at this point, I'm not sure we'd want it. Since we are a restaurant and unable to offer dine-in service, it doesn't make much sense to hire back servers and bartenders and staff.

Did you read the article about the lady who owns two spas and she got over $200,000 through this program, but her staff was upset because they were enjoying the paid time off...

I wouldn't hire people back just for the forgiveness part of it. However, having the funds available to help offset some costs of employees that we have retained is invaluable. 

22 hours ago, N201MKTurbo said:

The company my wife works for (she is the controller) received $320K last week. They are struggling to meet all the requirements for forgiveness. The biggest struggle is to get the executives in the company to agree that they need to follow the letter of the law.

I don't have any expertise in medicine, but I have some experience with this side of things as the controller at our dealerships.

I think the biggest factor in whether you received a loan or not is who you bank with. Some banks were helping their customers and others weren't. Wells Fargo for one basically kicked everyone to the curb. Some of the other big national banks only helped their big customers. I read about a number of businesses that worked with small local banks that were successful. There is really nothing financially in it for the banks, just about helping their customers.

I was able to secure PPP loans for all three of our dealerships. We are fortunate that we do not bank with one of the big names, we are with a smaller bank with branches just throughout Southern California. Having a long relationship with a smaller bank I think was a key. We also got way ahead of the game. From the first announcement, before it was even passed, I was working on it, gathering all the information I thought they "might" need. I was also telling everyone that was a business owner about it because it was not getting much press. Given the amount of money they were allocating for the program it was obvious that it was going to run out very quickly. The application period was to open Friday April 3rd. One Tuesday the 31st I had filled out the applications and sent them in to "be at the front of the line" so to speak. Late in the evening on the 2nd an updated application was online so I filled those out again and resubmitted to the bank on Friday the 3rd. On Saturday I got an email from the bank that they needed additional tax forms so I dropped what I was doing and drove to the dealerships to scan and email the additional information. For those looking to get a PPP loan or know of businesses that are trying to get the funds, time is of the essence. Additional funds are getting allocated but those will dry up fast as well. Get your application in and hopefully you have a good working relationship with your bank because that will be key.

On the forgiveness side of it there are a lot of different requirements in not only what can be forgiven but what is required to show forgiveness. I have seen different worksheets from multiple CPA firms as well as law firms. Parts of the worksheets agree and parts of them don't agree. Even the bank that we received the loans from don't have everything figured out on what kind of documentation the underwriters are going to require for the forgiveness aspect. They have given me some general guidelines but so I am gathering documentation, but I don't have final instructions or even a worksheet from them. It appears that the individual banks have the guidelines but are interpreting paperwork requirements differently and the government is leaving it up to them to determine the amount of forgiveness.

To your comment Rich about the company your wife works for, I think there will be a lot of fraud in this whole program given the size/scope of it and the fact that the government is not very good at oversight. Thankfully, the dealer that I work for is very much about following the letter of the law and our CPA is as well. It is a lot easier to just do it right and not worry about getting caught at some later date for doing it wrong. There are some things that can be done to help on the forgiveness side of it. The biggest thing is that it is actual cash out and not accrued, and it is an 8 week time frame from the date the loan funds. A company could help itself by paying attention to the date of the funding and if necessary pull a payroll ahead by a few days so that it falls inside the 8 week time frame for forgiveness. Accruing the payroll amounts doesn't count, it has to actually be paid out during that 8 week period.

If anyone is interested in chatting about it or has questions feel free to send me a PM. 

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1 hour ago, ilovecornfields said:

@DXB. Your solution seems much simpler. Don’t try to test people, just grow ventilators, hospitals and intensivisits.

I appreciate your suggestions, But I think we can agree to disagree.

Your assumptions regarding the fallacy of testing depend on the test having a low pre-test probability to begin with (and therefore a low PPV when positive). Unless you test a large number of people you have NO idea what the baseline prevalence of disease is. 0.2%, 2%, 20%? You don’t know, and therefore you can’t accurately calculate those values.

No test is perfect and no one will argue that. But they have a place in this outbreak and dismissing testing because it has its limitations seems like a huge mistake. If you use mortality as a proxy (which some have suggested) then your “most current” data will lag 15-40 days (average time from exposure to death) so by the time you see the effect of your interventions you’re weeks-month “behind the curve” so to speak. How far do you move down that exponential growth curve in a month? Then another 14-40 days to see how your next change plays out? No thanks! I’ll take my imperfect tests that can start to show trends in a few days than my also imperfect mortality data that’s putting me weeks behind what’s going on.

And by “effective treatment” I didn’t mean a miracle cure like what’s touted on television,  but even the things we’re currently doing that have already reduced mortality for critically ill patients (supportive  care, anticoagulation) and again point out that as long as we have ANY effect on the disease course (which we do) then your assumption is wrong. Your statement depended on mortality at home being equal to hospital mortality and it never has been. 
 

I don’t see how you have ANY chance of “marching patients to capacity” (which I think is you acknowledging the above statement) without extensive testing  I’ll take imperfect data that I can view trends in today vs. slightly better data that’s several weeks old anytime I’m dealing with exponential growth. I think it would be a mistake not to.

 

1. Being no stranger to the critical care world, I would never portray expansion of ICU capacity as simple - I would portray it as exquisitely painful and  resource intensive and sad but certainly doable. The capacity can certainly expand to match the patients - getting it right in the opposite direction is impossible at the moment.    Many of the skills are rapidly teachable and do not require high expertise at the hands on level, just experienced supervision.  The most experienced intensivists and ICU nurses and respiratory therapists will need to lead companies rather than platoons comprised of less experienced recruits who have been repurposed - for instance I was handy enough with a ventilator about 15 years ago and can get there quickly again. There are TONS of physicians and nurses at this medium level of ability to take care of the sickest sitting here with very few of our usual patients showing up. Save for the  few places who got hit hard early on, there is also tons of hospital capacity sitting empty while hospital finances crater.  Also GM is primed for manufacturing ventilators in Kokomo IN right now, and it's only going to get easier for them to do so as their infrastructure is fully established.  The wartime expansion and repurposing metaphor fits very well. 

2. I have not and would not dismiss a role for testing of the general population.  But i am tired of the common portrayal of "tests" as our savior and their absence as an excuse for inaction on easing social restrictions. That is also certainly misguided - the testing information is worthwhile from a research perspective but it is far from clear how to apply the knowledge.  We are certainly going to test many populations for serology and, and the high positive numbers will be more interpretable and MIGHT lead to significantly better outcomes from easing social restrictions, provided serology is at least a good correlate of the mechanism of immunity. Unfortunately we're only going to learn that answer down the road watching the real time events unfold. Only then will we understand the significance and utility of the various types of test results, not in the next month when the first round of hard decisions need to be made. Once that happens whoever is most right at the moment will smugly say I told you so - why didn't you do it the way I suggested? And no one will have learned a thing about how this type of knowledge is actually created. 

3. Let's be absolutely clear regarding what you are claiming regarding therapeutic innovation - you are claiming that we will find a treatment that significantly reduces transmission from infected patients and/or saves the critically ill ones if we just keep drastically trying to suppress the epidemic a bit longerI say the chances of that happening in the next year are so low  that they absolutely should not guide policy making at this moment.    How far have we come in treating other potentially life threatening respiratory viruses in the past two decades? Some minor critical care protocol refinements and one modestly effective class of neuramidase inhibitor drugs for influenza.        

 

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2 minutes ago, Skates97 said:

I wouldn't hire people back just for the forgiveness part of it. However, having the funds available to help offset some costs of employees that we have retained is invaluable. 

Exactly our thoughts...  This business is our restaurant and, since we can't have dine-in service and we only opened a week before our local shutdown, it makes no sense to bring all the staff back just to hang out.  We're doing what we can to support them with food deliveries and they're all getting unemployment now, so that's better than turning ourselves into an employment agency and trying to keep them busy.

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Richard,

Thank you for sharing your insight...

We are getting a broader picture from two angles around here... finance and healthcare...

 

The finance part sounds similar to the ADSB rebate program... proper documentation, and fast acting.... better than waiting too long...

Best regards,

-a-

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41 minutes ago, DXB said:

 

1. Being no stranger to the critical care world, I would never portray expansion of ICU capacity as simple - I would portray it as exquisitely painful and  resource intensive and sad but certainly doable. The capacity can certainly expand to match the patients - getting it right in the opposite direction is impossible at the moment.    Many of the skills are rapidly teachable and do not require high expertise at the hands on level, just experienced supervision.  The most experienced intensivists and ICU nurses and respiratory therapists will need to lead companies rather than platoons comprised of less experienced recruits who have been repurposed - for instance I was handy enough with a ventilator about 15 years ago and can get there quickly again. There are TONS of physicians and nurses at this medium level of ability to take care of the sickest sitting here with very few of our usual patients showing up. Save for the  few places who got hit hard early on, there is also tons of hospital capacity sitting empty while hospital finances crater.  Also GM is primed for manufacturing ventilators in Kokomo IN right now, and it's only going to get easier for them to do so as their infrastructure is fully established.  The wartime expansion and repurposing metaphor fits very well. 

2. I have not and would not dismiss a role for testing of the general population.  But i am tired of the common portrayal of "tests" as our savior and their absence as an excuse for inaction on easing social restrictions. That is also certainly misguided - the testing information is worthwhile from a research perspective but it is far from clear how to apply the knowledge.  We are certainly going to test many populations for serology and, and the high positive numbers will be more interpretable and MIGHT lead to significantly better outcomes from easing social restrictions, provided serology is at least a good correlate of the mechanism of immunity. Unfortunately we're only going to learn that answer down the road watching the real time events unfold. Only then will we understand the significance and utility of the various types of test results, not in the next month when the first round of hard decisions need to be made. Once that happens whoever is most right at the moment will smugly say I told you so - why didn't you do it the way I suggested? And no one will have learned a thing about how this type of knowledge is actually created. 

3. Let's be absolutely clear regarding what you are claiming regarding therapeutic innovation - you are claiming that we will find a treatment that significantly reduces transmission from infected patients and/or saves the critically ill ones if we just keep drastically trying to suppress the epidemic a bit longerI say the chances of that happening in the next year are so low  that they absolutely should not guide policy making at this moment.    How far have we come in treating other potentially life threatening respiratory viruses in the past two decades? Some minor critical care protocol refinements and one modestly effective class of neuramidase inhibitor drugs for influenza.        

 

Well, I think I actually agree with you on #1 and #2. As far as #3 goes, I agree with everything except the part that I “am claiming...therapeutic innovation.” I thought I was pretty clear that I am NOT claiming we will have a miracle cure, but that as our understanding of the pathophysiology and treatment modalities improve, we will continue to make incremental improvements in our ability to care for this population and alter the disease course. How quickly and by how much remains to be seen. I believe my exact words were:

 

And by “effective treatment” I didn’t mean a miracle cure like what’s touted on television,  but even the things we’re currently doing that have already reduced mortality for critically ill patients.

We’re already learning more about the disease and possible ways to treat it every day. First it was “like the flu” then it was a “cytokine storm” then ARDS but with surprisingly normal lung compliance and now we’re just starting to appreciate the thrombotic complications that appeared to be underappreciated early on as potential targets for therapy (I’m not taking about APC which was a failure but more traditional treatments of coagulopathies which seem to more closely resemble DIC). This would certainly explain the relationship of d-dimer to mortality, the profound hypoxia with minimal radiographic features and the multi organ failure in the absence of the traditional septic shock/MODS picture. 
 

I get the feeling we’re getting lost in the details and we actually agree more than we disagree, but I’m sure you will correct me if I’m wrong. ;-)

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There has been some interesting discussion here.  Since I am one of those guys who just can't walk past a pot without giving it a stir or two I will add some thoughts.  Questions that would be nice to have answers to.  How many of the current virus deaths would have died from something else in the next 6 months or so?  That number is certainly not zero.  Maybe next years flu mortality will be unusually low because the COVID got them now.  How many people are staying home because of fear of the hospital and dying from otherwise treatable conditions.  Not sure how easing things would change that number but I'm sure the number isn't zero.  Also how many deaths are there going to be because of the lockdown?  Suicide, accidental overdose?  Before COVID one of the recurring big stories was the opiate epidemic.  That was killing people plenty fast too.  I would be shocked if those numbers haven't gotten worse.  Put me in the group that would like to see individual states and cities decide when to let up if for no other reason than people are going to start anyway.  I will not confirm or deny reports that I got a blackmarket haircut in my barbers garage the other day.

As for miracle cure I have my doubts but for a promising treatment/prophylactic I would put my money on convalescent serum.

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It would be interesting to see how people would react if they were presented with modelling data that includes a forecast timeline instead of uninformative cartoon models that have almost no meaning. Just because someone isn't an Epidemiologist doesn't mean they don't have the ability to understand and interpret presented data.

Couple the timeline outlook of Anderson's model shown below with the Faucci's NEJM article that states: "This suggests that the overall clinical consequences of Covid-19 may ultimately be more akin to those of a severe seasonal influenza (which has a case fatality rate of approximately 0.1%)". At that point one has to ask, what does the economic impact model overlay look like? Neglecting any quantitative information, does this whole mess pass the sniff test?

As uncomfortable as it is, there will be an optimal trade-off between unrecoverable economic destruction and death. China didn't release reliable data (for whatever reason) to allow for accurate forecast models to be developed and now the rest of the world has uncomfortable choices to make. It would be nice to have complete data presented to the public (without having to hunt it down) so those uncomfortable decisions can be made.

2079728383_ScreenShot2020-04-26at4_43_39PM.png.b450582b674579400fe5c46fe4b7d90b.png

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30567-5/fulltext

 

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Appreciative of the informed discussion above. One of the better series of articles I've read from a policy perspective is Tomas Pueyo's excellent series in Medium: "The Hammer and the Dance". Deep data and analysis made accessible.

https://medium.com/@tomaspueyo/coronavirus-the-hammer-and-the-dance-be9337092b56

Basically, the initial social distancing measures were - as every rational person now recognizes -  necessary to slow the exponential spread of the virus, and to buy time for health care systems to get to the point where they are not overwhelmed trying to keep large numbers of people breathing, and to allow time for therapeutics and treatment modalities to be worked out. That was the "hammer". Hopefully, in most jurisdictions, this will give way to the "dance"...which will continue until either there is an effective vaccine or until there is sufficient herd immunity as a result of exposure, neither of which will happen soon.

https://medium.com/@tomaspueyo/coronavirus-learning-how-to-dance-b8420170203e

Some countries are already through the Hammer phase, and are relaxing their lockdowns. It's not "normal", but the policy goal is to combine measures that bring economies back on line, while keeping the virus’ transmission rate below 1 so that it doesn't spike again.

https://medium.com/@tomaspueyo/coronavirus-the-basic-dance-steps-everybody-can-follow-b3d216daa343

Definitely worth the 20m read. Almost as educational as MS.

 

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It's interesting that in all of Japan, they report fewer than 400 coronavirus deaths...yet the USA reports more than 49,000 coronavirus deaths...and Tokyo is much more populous than is NYC.  Are they doing something different or are their reporting criteria not the same?  Having worked extensively throughout Japan, for many years, I am confident there's no coverup there...it's just not their nature.  But they didn't impost a nationwide lockdown, like we did.  I welcome the input and perspectives of the experts here. And, clearly, we've got some really well-qualified MS folks who have provided some great perspective. 

Source: https://www.nytimes.com/interactive/2020/world/coronavirus-maps.html#countries

 

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14 hours ago, David_H said:

It would be interesting to see how people would react if they were presented with modelling data that includes a forecast timeline instead of uninformative cartoon models that have almost no meaning. Just because someone isn't an Epidemiologist doesn't mean they don't have the ability to understand and interpret presented data.

 

14 hours ago, David_H said:

It would be nice to have complete data presented to the public (without having to hunt it down) so those uncomfortable decisions can be made.

Agreed!    Interesting that the y-axis is not labelled.   Seems to me that's incredibly pertinent to the discussion.

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Ross’ NYT article needs joining / free account...

I have been through many countries, including Japan...

The corporate environment was very similar To the US and Europe...

But, to see how this virus is being transmitted... one may have to see 24/7 into people’s private lives... tightly packed into public transportation On the way to work can’t be very good for virus defense...

distance, masks, not sitting directly across the table, no face touching... coughing, sneezing, etiquette...


Getting educated about what works...  getting the word out...   The equivalent of Dr. Ruth putting condoms on a cucumber...

Since the virus can be carried for 14 days without showing any symptoms...  we may be showing differences in how open our society is compared to others...  and how much close contact we have...

I don’t recall going to Japan, shaking hands, high fives, or hugs... lots of distant bowing towards each other...  :)

 

Expect the facts to change...  when the facts change, the methods of defense will change as well...

discuss openly...

Keep one eye looking forwards for opportunity... the other looking back to remember our history...

more people are going back to work today in NJ...  should be interesting... :)

Best regards,

-a-

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The current discussion in my area is what is going to happen with our hospital with our governor treating the whole state as if it's Detroit (full lock down).  Our rural U.P. probably has one of the lowest COVID-19 infection and death rates in the entire country, and we are a very well defined area.  75% of our border is Lake Superior or Lake Michigan, with a 5 mile suspension bridge (the Mackinaw Bridge) separating the U.P. from the rest of Michigan.  Currently we would need to increase our fatality rate 30 times to meet the published flue fatality rate.  Our INFECTION rate is 6 times lower than the flue FATALITY rate.

Our hospital is the only hospital within 90-100 miles.  They were on the brink of bankruptcy a year ago, and not a single other hospital system that looked at us would buy us.  Our only option was dig our way out.  Hard work and a ton of local support has brought the hospital to within a hairs width of obtaining a 50 million dollar loan to keep them solvent.  And then we got the lock down.  No non-essential services or surgeries for 6 weeks now.  My brother ended up there during this time with a bleeding stomach (passing out and taken by ambulance).  His wife visited him during his couple day hospital stay and said the hospital was a ghost town.  Almost closed down.  They've had 5 admitted cases of COVID-19 in 6 weeks (two from Wisconsin).

So, we contemplate the likelihood this hospital will financially make it, since they were so close to shuttering the doors prior to this event.  And, if they don't make it, how many will die in the next 5-10 years as they lay in the ambulance for their 2 hour run to another hospital.  Taking COVID-19 seriously, sure.  Applying strategies and policies that make sense ..... should be a no-brainer., unless left to a completely incompetent politician.

Tom

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 Thanks @carusoam - for me it showed free COVID info and didn't require a subscription.  So, here are screenshots of the USA info and Japan's (and Singapore and Chile, to boot). True, the Japanese don't shake hands...but I worked for a company with an office in Tokyo and I was there (and all over the country) monthly for years.  The trains and queues and businesses are definitely packed snugly on a regular basis, at least in the cities.  I also got to spend a few weeks in Singapore on a couple trips...and that was like Japan but with hand shaking.  :D  I've never been to Chile (would love to), but their figures are also pretty low. 

 

Screen Shot 2020-04-27 at 8.27.10 AM.png

Screen Shot 2020-04-27 at 8.28.00 AM.png

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