My Child has Acute Appendicitis. Should We Operate ?

This is a modern-day study relevant to many parents who bring their child to an emergency room. Almost every parent knows the signs and symptoms of acute appendicitis, right lower quadrant pain, nausea and vomiting, and fever.  

In the emergency department, the physicians formulate a quick differential diagnosis to determine the alternatives.  Some viral infections cause similar or even identical symptoms and signs.

The appendix is a normal part of the digestive tract located at the junction of the small intestine where it enters into the ascending colon. Along with symptoms of acute appendicitis, the signs of right lower quadrant point tenderness strengthen the possibility of acute appendicitis. Viral gastroenteritis is very common in children and can mimic appendicitis.

A ruptured appendix can lead to an abscess or diffuse peritonitis, which could lead to sepsis be a life-threatening complication. A one time this decision was critical when powerful antibiotics were not always readily available.  Complications and disability were much more common.

There have been articles contrasting the safety and efficacy of nonsurgical treatment from 2014. More recently in 2017 a study revealed some changes in outcomes. The 2017 group included over 1000 patients enrolled in a randomized group of patients assigned by the physicians doing the study.  Although making this study more accurate it created difficulties for parents to enroll their children.

How to find McBurney's Point

 Conclusions

Among children with uncomplicated appendicitis, an initial nonoperative management strategy with antibiotics alone had a success rate of 67.1% and, compared with urgent surgery, was associated with statistically significantly fewer disability days at 1 year. However, there was a substantial loss to follow-up, the comparison with the prespecified threshold for an acceptable success rate of nonoperative management was not statistically significant, and the hypothesized difference in disability days was not me

Limitations

This study has several limitations. First, the results of this study are only applicable to a limited percentage of children who present with acute appendicitis. Due to the inclusion-exclusion criteria, only 19.3% of patients with appendicitis treated at the participating sites qualified for this study. These criteria were intentionally selected based on the available data in the literature related to the safety and efficacy of nonoperative management for children and to ensure consensus across the participating institutions. Also, all the participating sites are tertiary children’s hospitals whose patient population may include a lower proportion of children meeting eligibility criteria. Second, the nonrandomized treatment allocation potentially allows for treatment selection bias, where treatment may be affected by participant characteristics, and those choosing nonoperative management differ, on average, from those choosing surgery. However, several steps to minimize this were taken including the use of a standardized enrollment script and decision aid, specific inclusion and exclusion criteria, standardized treatment protocols and algorithms, and obtaining agreement to participate from all participating surgeons prior to beginning the study. Furthermore, treatment decision-making in clinical practice is affected by the biases of patients, families, and surgeons, suggesting that a patient choice treatment allocation may be more reflective of current practice. Moreover, robust inferential methods to aid in accounting for treatment confounding bias were used. Third, the generalizability of the results may be limited by the substantial rates of incomplete follow-up.

ref:

Cash  CL, Frazee  RC, Abernathy  SW,  et al.  A prospective treatment protocol for outpatient laparoscopic appendectomy for acute appendicitis.   J Am Coll Surg. 2012;215(1):101-105. doi:10.1016/j.jamcollsurg.2012.02.024PubMedGoogle Scholar

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Kocataş  A, Gönenç  M, Bozkurt  MA, Karabulut  M, Gemici  E, Alış  H.  Comparison of open and laparoscopic appendectomy in uncomplicated appendicitis: a prospective randomized clinical trial.   Ulus Travma Acil Cerrahi Derg. 2013;19(3):200-204. doi:10.5505/tjtes.2013.58234PubMedGoogle Scholar

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Minneci  PC, Mahida  JB, Lodwick  DL,  et al.  Effectiveness of patient choice in nonoperative vs surgical management of pediatric uncomplicated acute appendicitis.   JAMA Surg. 2016;151(5):408-415. doi:10.1001/jamasurg.2015.4534

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Salminen  P, Paajanen  H, Rautio  T,  et al.  Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: the APPAC randomized clinical trial.   JAMA. 2015;313(23):2340-2348. doi:10.1001/jama.2015.6154

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Fitzmaurice  GJ, McWilliams  B, Hurreiz  H, Epanomeritakis  E.  Antibiotics versus appendectomy in the management of acute appendicitis: a review of the current evidence.   Can J Surg. 2011;54(5):307-314. doi:10.1503/cjs.006610PubMedGoogle Scholar

Association of Nonoperative Management Using Antibiotic Therapy vs Laparoscopic Appendectomy With Treatment Success and Disability Days in Children With Uncomplicated Appendicitis | Emergency Medicine | JAMA | JAMA Network

https://jamanetwork.com/journals/jama/fullarticle/2768929?guestAccessKey=3596f1a4-2e25-4247-a1f5-2fba7edb444e&utm_source=silverchair&utm_medium=email&utm_campaign=article_alert-jama&utm_content=etoc&utm_term=081120

The Pandemic Could Be Worse in the Winter of 2020-21 - The Atlantic

       

Here in Southern California, we are experiencing a rather mild summer. We have had only one week of 100+ weather. Climate change does not necessarily mean warming. What we can expect is wider and more extreme changes in weather.

It is not too early to think about the coming fall and winter while hiking, camping, sailing, surfing, biking, or whatever your outdoor sport may be.  

It is not hard to distance and avoid closed spaces in spring, summer, and fall.  Covid-19 will necessitate some modifications in lifestyle.  Many Southern Californians categorize cold weather when the temperature gets below 60 degrees, and there is a mist or fog.  The lack of sunshine causes some Californians to shelter in place. (ie, inside)

Throughout the pandemic, one lodestar of public-health advice has come down to three words: Do things outside. For nearly five months now, the outdoors has served as a vital social release valve—a space where people can still eat, drink, relax, exercise, and worship together in relative safety.

Later this year, that precious space will become far less welcoming in much of the U.S. “What do you do when nobody wants to go to the beach on some cold November day?” Andrew Noymer, a public-health professor at UC Irvine, said to me. “People are going to want to go to bowling alleys and whatnot, and that’s a recipe for disaster, honestly—particularly if they don't want to wear masks.”

People will have to get used to wearing a mask. If you insist on going into closed spaces, wear a mask, and practice distancing. Take sanitizer with you, wash, wash,  wash, and don't be timid about cleaning your space. Think positive and use it as a fashion statement, with colors, artwork, and statements. Humorous captions bring smiles. Emoji may become the next think in masks.  LEDs and Gif's may be the next rage. Think positive, do not attach political ambition with your facial disguises.  We are in a divisive time in America.  Don't make it worse.  Your mask is not going to change an election.  In fact, by November the election will be over.

In recent interviews with Noymer and other experts, I caught glimpses of the winter to come, and what I saw was bleak, even compared with what Americans have already experienced. The winter will be worse—for the quality of daily life in America and, possibly, for the course of the pandemic itself.

“There really is no easy way to socialize during late fall [and] winter in large parts of the country if you're not doing it outside,”  

                

There are ways to extend the outdoor time by adopting cold-weather gear. People in Northern climates do it all the time. Wearing layered clothing, parkas and slacks designed for colder climates.  Minnesotan's go ice fishing, wearing ear protection and gloves make outdoor sports and activities doable. They do not give up outdoor athletics, adopting cross country skiing, outdoor skating. Ashish Jha, the director of the Harvard Global Health Institute, told me. “Could I have people over my house for two hours on a Sunday morning in December? Barring really good testing, probably not.”

That’s because the risk of spreading the coronavirus is heightened in enclosed spaces. Outdoors, there is enough air for the virus to be “rapidly diluted,” as well as the helpful “virus-killing action of sunlight,” explains Linsey Marr, an engineering professor at Virginia Tech. Indoors, she told me, “the virus can build up” and be more easily inhaled, and “if space is heated, it can lead to dry air,” which is more hospitable to the virus.

The experts I consulted were very concerned about the risks of indoor gatherings, but mentioned several measures that could make them safer if people decide to have them anyway: stay at least six feet apart, wear a mask, wipe down frequently touched surfaces, meet in a building with sufficient filters in its ventilation system, use a portable air purifier and a humidifier, and stay clear of crowded rooms. (If all of that sounds onerous, it’s because spending time indoors with people you don’t live with is really risky—and better avoided if you can help it.)

Experts have emphasized sanitizing, distancing, and avoiding indoor crowds.  However, they have not addressed other aspects of prevention.  Early prevention emphasized the prevention of infection by masking.

Nothing much was said about aerosolizing the virus.  Improving ventilation is a means of dilution, and HEPA filtering can reduce viral exposure.  Opening a window or increasing room airflow

There is a big dispute in the scientific community, however, about both the size and the behavior of these particles, and the resolution of that question would change many recommendations about staying safe. Many scientists believe that the virus is emitted from our mouths also in much smaller particles, which are infectious but also tiny enough that they can remain suspended in the air, float around, be pushed by air currents, and accumulate in enclosed spaces—because of their small size, they are not as subject to gravity’s downward pull. Don Milton, a medical doctor and an environmental-health professor at the University of Maryland compares larger droplets “to the spray from a Windex dispenser” and the smaller, airborne particles (aerosols) “to the mist from an ultrasonic humidifier.” Clearly, it’s enough to merely step back—distance—to avoid the former, but distancing alone would not be enough to avoid breathing in the latter.

The disagreement got heated enough that earlier this month, hundreds of scientists around the world signed a letter, pleading with the WHO to acknowledge these smaller particles as an extra mode of transmission and to update its guidelines accordingly. Some experts I spoke with told me that they had been trying to convince the WHO to take the possibility of airborne transmission since March and that the open letter was borne out of frustration about lack of progress. Signatories who study aerosols—the smaller, floating particles—including professor Linsey Marr of Virginia Tech and Jimenez, told me that they don’t disagree with the idea that transmission at close range represents the most risk, as per the WHO and CDC guidelines. But they disagree that the dominance of close-contact transmission implies that ballistic trajectories or larger respiratory droplets are the overwhelming modes of transmission. In their view, even some portion of that close-contact transmission is likely due to aerosols, and many experts told me that they think even particles bigger than the WHO’s definition of respiratory droplets (larger than 5-10 microns in diameter) can float for a bit. In response, the WHO published a scientific brief on July 9 acknowledging the possibility of airborne transmission but still concluding that COVID-19 is “primarily transmitted” between people through respiratory droplets and touching and that the  question needs “further study.”

Anyone wanting to learn more about airborne disease must read the article in the Atlantic Magazine

Now is the time to give individual thought to the coming winter season.  Remember winter clothing goes on the shelves in August and September.  Preparation may give you a more enjoyable winter.

The Pandemic Could Be Worse in the Winter of 2020-21 - The Atlantic

Effect of Convalescent Plasma Therapy on Time to Clinical Improvement in Patients With Severe and Life-threatening COVID-19: A Randomized Clinical Trial | JAMA | JAMA Network

Key Points

During the early days of the Coronavirus pandemic from January 2020 through March 2020, there was confusion, misinformation and disinformation coming from the media, China, CDC, and the White House.  There were only two credible sources for information Dr. Anthony Fauci and Dr. Deborah Birx. Numerous polls indicated trust in Fauci and Birx.  The White House frequently gave contradictory statements during live broadcasts.

One study has appeared regarding a potential treatment for acute disease

What is the effect of convalescent plasma therapy added to standard treatment, compared with standard treatment alone, on clinical outcomes in patients with severe or life-threatening coronavirus disease 2019 (COVID-19)?

This randomized clinical trial that included 103 patients and was terminated early, the hazard ratio for time to clinical improvement within 28 days in the convalescent plasma group vs the standard treatment group was 1.40 and was not statistically significant.

Meaning  Among patients with severe or life-threatening COVID-19, convalescent plasma therapy added to standard treatment did not significantly improve the time to clinical improvement within 28 days, although the trial was terminated early and may have been underpowered to detect a clinically important difference.

Effect of Convalescent Plasma Therapy on Time to Clinical Improvement in Patients With Severe and Life-threatening COVID-19: A Randomized Clinical Trial | JAMA | JAMA Network

References

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Wang  D, Hu  B, Hu  C,  et al.  Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China.   JAMA. 2020;323(11):1061-1069. doi:10.1001/jama.2020.1585

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Wu  Z, McGoogan  JM.  Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention.   JAMA. 2020;323(13):1239-1242. doi:10.1001/jama.2020.2648

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Garraud  O, Heshmati  F, Pozzetto  B,  et al.  Plasma therapy against infectious pathogens, as of yesterday, today and tomorrow.   Transfus Clin Biol. 2016;23(1):39-44. doi:10.1016/j.tracli.2015.12.003PubMedGoogle ScholarCrossref

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Cheng  Y, Wong  R, Soo  YO,  et al.  Use of convalescent plasma therapy in SARS patients in Hong Kong.   Eur J Clin Microbiol Infect Dis. 2005;24(1):44-46. doi:10.1007/s10096-004-1271-9PubMedGoogle ScholarCrossref

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Yeh  KM, Chiueh  TS, Siu  LK,  et al.  Experience of using convalescent plasma for severe acute respiratory syndrome among healthcare workers in a Taiwan hospital.   J Antimicrob Chemother. 2005;56(5):919-922. doi:10.1093/jac/dki346PubMedGoogle ScholarCrossref

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Arabi  YM, Hajeer  AH, Luke  T,  et al.  Feasibility of using convalescent plasma immunotherapy for MERS-CoV infection, Saudi Arabia.   Emerg Infect Dis. 2016;22(9):1554-1561. doi:10.3201/eid2209.151164PubMedGoogle ScholarCrossref

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Kraft  CS, Hewlett  AL, Koepsell  S,  et al; Nebraska Biocontainment Unit and the Emory Serious Communicable Diseases Unit.  The use of TKM-100802 and convalescent plasma in 2 patients with Ebola virus disease in the United States.   Clin Infect Dis. 2015;61(4):496-502. doi:10.1093/cid/civ334PubMedGoogle ScholarCrossref

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Shen  C, Wang  Z, Zhao  F,  et al.  Treatment of 5 critically ill patients with COVID-19 with convalescent plasma.   JAMA. 2020;323(16):1582-1589. doi:10.1001/jama.2020.4783

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Duan  K, Liu  B, Li  C,  et al.  Effectiveness of convalescent plasma therapy in severe COVID-19 patients.   Proc Natl Acad Sci U S A. 2020;117(17):9490-9496. doi:10.1073/pnas.2004168117PubMedGoogle ScholarCrossref

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Recommendations for Investigational COVID-19 Convalescent Plasma. US FDA. Published May 1, 2020. Accessed May 26, 2020. https://www.fda.gov/vaccines-blood-biologics/investigational-new-drug-ind-or-device-exemption-ide-process-cber/recommendations-investigational-covid-19-convalescent-plasma

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Position Paper on Use of Convalescent Plasma, Serum or Immune Globulin Concentrates as an Element in Response to an Emerging Virus. In: Network WBR, ed. 2017. Accessed April 18, 2020. https://www.who.int/bloodproducts/brn/en/

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National Health Commission of the People’s Republic of China. Covid-19 treatment plan (trial version 6). Accessed April 20, 2020. http://www.nhc.gov.cn/yzygj/s7653p/202002/8334a8326dd94d329df351d7da8aefc2/files/b218cfeb1bc54639af227f922bf6b817

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Wang  Y, Zhang  D, Du  G,  et al.  Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial.   Lancet. 2020;395(10236):1569-1578. doi:10.1016/S0140-6736(20)31022-9PubMedGoogle ScholarCrossref

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Daily update on covid-19. National Health Commission of the People’s Republic of China. Accessed May 24, 2020. http://www.nhc.gov.cn/xcs/yqtb/202003/f01fc26a8a7b48debe194bd1277fdba3.shtml

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Beigel  JH, Aga  E, Elie-Turenne  MC,  et al; IRC005 Study Team.  Anti-influenza immune plasma for the treatment of patients with severe influenza A: a randomised, double-blind, phase 3 trial.   Lancet Respir Med. 2019;7(11):941-950. doi:10.1016/S2213-2600(19)30199-7PubMedGoogle ScholarCrossref

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Soo  YO, Cheng  Y, Wong  R,  et al.  Retrospective comparison of convalescent plasma with continuing high-dose methylprednisolone treatment in SARS patients.   Clin Microbiol Infect. 2004;10(7):676-678. doi:10.1111/j.1469-0691.2004.00956.xPubMedGoogle ScholarCrossref

Trump signs order expanding use of virtual doctors

Trump signs order expanding use of virtual doctors

© Doug Mills

Physicians and patients sigh a breath of relief.  Telehealth, something pressed into service due to the Coronavirus pandemic has become a way of affording relief and more health care accessibility to more patients will become a standard of care

President Trump on Monday signed an executive order seeking to expand the use of virtual doctor visits, as his administration looks to highlight achievements in health care. 

The administration waived certain regulatory barriers to video and phone calls with doctors, known as telehealth when the coronavirus pandemic struck and many people were stuck at home. Now, the administration is looking to make some of those changes permanent, arguing the moves will provide another option for patients to talk to their doctors. 

The order calls on the secretary of Health and Human Services to issue rules within 60 days making some of the changes permanent. 

“Today I’m taking action to make sure telehealth is here to stay,” Trump said during a White House news briefing. 

It is unclear when any of the changes proposed by these orders will actually take effect, though, given that there are still regulatory processes that take time to play out.  There are regulations still in existence for payers to reimburse for telehealth charges after the pandemic ends. These include restrictions in urban areas, telehealth limited to established patients in a doctor's panel, and other limitations.

“In an earlier age, doctors commonly made house calls,” Centers for Medicare and Medicaid Service Administrator Seema Verma said in a statement. “Given how effectively and efficiently the healthcare system has adapted to the advent of telehealth, it’s become increasingly clear that it is poised to resurrect that tradition in modern form. Thanks to President Trump, the telehealth genie is not going back into the bottle.”

The order also calls on HHS to propose a new model that can be tested for how Medicare will pay for some health services in rural areas, with the goal of improving care in rural areas. 

Telehealth Services: What Medicare Covers

Tags:  CMS CENTERS FOR MEDICARE AND MEDICAID SERVICES DONALD TRUMP TELEHEALTH CORONAVIRUS COVID-19

https://tinyurl.com/y5rfymgq

Body mass index (BMI) is a miscalculation

 

Most of us recognize BMI as a calculation for body mass index.  Physicians like the term since it gives them a number indicating obesity.

However, BMI has ignored the weight of evolution and elementary physics according to Alan Finkel (Alan Finkel is an electrical engineer, neuroscientist, and Chief Scientist of Australia.).

It naturally got me wondering: how scientific is the BMI?

It may be a 188-year-old staple of health statistics, but modern health professionals have documented many flaws. For starters, the BMI doesn’t distinguish whether body weight comes from fat or muscle, so Michelin Man and the Terminator might have the same BMI despite their very obvious differences in fat and muscle distribution. Neither does it factor in other key health criteria such as age, gender, or body type. For instance, people who deposit fat around their waists are at a higher risk of disease than people who deposit it on their hips and thighs.

My concern, however, is that the BMI ignores elementary physics.

The problem traces back to Lambert Adolphe Jacques Quetelet, the Belgian statistician who invented the BMI in 1830. Quetelet failed to consider the mathematics of scaling. He defined the BMI as weight divided by height squared. Note, however, that weight is proportional to volume, which is proportional to height cubed. The upshot of this is that all other things being equal, BMI varies directly with height, which it clearly should not.

For instance, observe the formula

Perhaps the fault goes back to Jonathan Swift’s wildly popular 1726 tale of Gulliver’s Travels. Swift’s giant Brobdingnagians and tiny Lilliputians could not actually exist. 

For example, consider a giant twice as tall as myself but with exactly my shape and looks. If the giant was standing on a beach with no other objects in sight, a far-off observer could not tell that he was not me. Because his mass would be proportional to my height cubed, my double-height doppelganger would weigh eight times more than me. However, the cross-sectional area of his legs would be proportional to my height squared, so they would be only four times stronger. Those poor bones! They would be over-stressed by carrying eight times the weight. My giant double would collapse under his own weight. Now create a version of me half my height. He would weigh one-eighth of what I weigh, but his leg bones and muscles would be twice as strong as they needed to be. 

Nature understands this, which is why elephants look like elephants and ants like ants. The BMI formula does not share this insight. It can make tall people appear overweight when they are not. Compared with a 152 cm (five foot) individual with a ‘normal’ BMI of 22, an identically proportioned 183 cm (six foot) person would have a BMI of 26.5 – overweight.

Based on BMI ranges, most Australians are too plump: 28% are classified as obese, 35% overweight, 35% normal and a mere 2% underweight. No doubt this skewing towards being overweight reflects a genuine health problem. But it might be affected by the increase in the average height of the population since 1830. 

Fortunately for Quetelet, there were few Terminators back then to question his BMI. And fortunately for Jonathan Swift his satire was not questioned by an incurable engineer who would have pointed out that the Brobdingnagian giants, at 12 times the height of Gulliver, would have weighed more than 100 tonnes, with a BMI in the hundreds.

I don’t suggest changing the way the BMI is calculated, despite its flaws, because we would not want to throw out the past 188 years of BMI records (noting that in most cases the raw data – height and weight – will not have been kept). Instead, we could adjust the standard BMI numerical ranges for underweight, normal weight, overweight and obese based on height, and perhaps even gender and body shape.

Body mass index miscalculation - Cosmos Magazine

Sudden Death at Home. As coronavirus surges, Houston confronts its hidden toll:

HOUSTON — When Karen Salazar stopped by to check on her mother on the evening of June 22, she found her in worse shape than she expected. Her mother, Felipa Medellín, 54, had been complaining about chest pains and fatigue, symptoms that she attributed to a new diabetes treatment she’d started days earlier.

Medellín, who had seen a doctor that day, insisted she was fine. But Salazar, 29, noticed that when Medellín lay down, her chest was rising and falling rapidly — as if she couldn’t catch her breath.

“I grabbed her hand and I said: ‘I’m sorry. I know you don’t want to go to the hospital, but I’m calling the ambulance,’” Salazar said.

While Salazar was on the phone with a 911 dispatcher, her mother suddenly passed out. Then she stopped breathing.

“Mom! Mom!” Salazar remembers shouting, trying to rouse her.

Karen Salazar holds a picture of her mother, Felipa Medellín, outside of her mother’s home in Houston on Tuesday.Fred Agho / for NBC News

With the dispatcher on speakerphone, Salazar attempted CPR, repeatedly pressing her hands down on her mother’s chest, silently praying for her to startle back to life. But by the time Houston paramedics arrived at her home in northwest Houston, Medellín was dead.

Days later, an autopsy revealed the primary cause: COVID-19.

“We never thought it was COVID,” Salazar said. “We didn’t even realize she had it.”

Medellín’s death is part of a troubling trend in Houston.

As coronavirus cases surge, inundating hospitals and leading to testing shortages, a rapidly growing number of Houston area residents are dying at home, according to an NBC News and ProPublica review of Houston Fire Department data. An increasing number of these at-home deaths have been confirmed to be the result of COVID-19, Harris County medical examiner data shows.

The previously unreported jump in people dying at home is the latest indicator of a mounting crisis in a region beset by one of the nation’s worst and fastest-growing coronavirus outbreaks. On Tuesday, a record 3,851 people were hospitalized for the coronavirus in the Houston region, exceeding normal intensive care capacity and sending some hospitals scrambling to find additional staff and space.

The uptick in the number of people dying before they can even reach a hospital in Houston draws parallels to what happened in New York City in March and April, when there was a spike in the number of times firefighters responded to medical calls, only to discover that the person in need of help had already died. These increases also echo those reported during outbreaks in Detroit and Boston, when the number of people dying at home jumped as coronavirus cases surged.

While far more people died of COVID-19 in those cities than have died so far in Houston, researchers and paramedics say that the trend of sudden at-home deaths in Texas’ largest city is concerning because it shows that the virus’s toll may be deeper than what appears in official death tallies and daily hospitalization reports.

As coronavirus surges, Houston confronts its hidden toll: People dying at home

Changing the Way We Deliver Care -

The daily routine of medical practice has changed.  For several months patients deferred visits to their physicians for fear of contracting Covid-19 and the idea that most clinics would be overwhelmed with Covid-19 patients.  While the volume of clinic visits declined significantly due to those fears, most diagnoses of Covid-19 are made in the outpatient setting of physician offices. (Study)

The pandemic has rocked the financial bedrock of healthcare for small or solo practice. During this pandemic, many patients have chosen to defer or forgo medical visits at a high cost for reimbursement to these practices.  Many physicians had to furlough long time employees from their administrative staff. In some cases even employed physicians were furloughed or terminated. Some of these medical clinics were eligible for the CARES act, which will supplement payroll expenses.  However ongoing expenses, leases, malpractice insurance, health insurance premiums, operating expenses rapidly drained cash reserves.

Some of the changes that have occurred rapidly are the use of telehealth, remote monitoring, and new procedures for patient visits that use online appointments, preregistration, and even messaging systems that instruct waiting patients in their car as to when they can enter the office. This improves efficiency and perhaps will remain a standard for patient-centered medical care.

Gradually as social distancing decreases when the pandemic becomes more controlled new protocols will remain in place.

The lack of personal protective equipment is not quite as acute as several months ago. Both patients and providers have better access to masks.

Biological Age Testing: How old am I ?

Biological Age vs. Chronological Age

There are many ways of determining biological age as compared to determining chronological age. The image above graphically illustrates the difference.  A number of metrics have been used to determine the biological age. This relates to the health of the liver, kidneys, immune status, genetic markers such as length of telomeres on chromosomes.  Some of these tests are readily available and at a low cost.  Most can be obtained with a  blood sample for about eighty dollars.

Metrics:

Standard Complete Blood Count (CBC) Red blood cell count, white blood cell count.

Standard Chemistry Panel. Liver profile, Renal Profile, 

C Reactive Protein: Inflammatory measure.

Telomere length.

White House blocks CDC from testifying on reopening schools next week

(CNN)"The White House is blocking US Centers for Disease Control and Prevention Director Dr. Robert Redfield and other officials from the agency from testifying before a House Education and Labor Committee hearing on reopening schools next week, just as the debate over sending children back to classrooms has flared up across the US.

White House officials informed the committee of its decision in an email, a staff member on the House panel told CNN.

"Dr. Redfield has testified on the Hill at least four times over the last three months. We need our doctors focused on the pandemic response," a White House official said, confirming the decision to block the CDC's participation in the hearing.

But a spokesman for the House Education and Labor Committee said the panel had requested testimony from any CDC official, not necessarily Redfield.

"We asked for anyone at CDC who could testify at the hearing. The invite was not for Dr. Redfield or no one," the official said.

House Education and Labor Chairman Bobby Scott said the testimony from CDC officials is critical to understanding how scientists would manage the reopening of US schools.

"It is alarming that the Trump administration is preventing the CDC from appearing before the Committee at a time when its expertise and guidance is so critical to the health and safety of students, parents, and educators," the Virginia Democrat said in a statement.

CDC officials have delayed the release of new recommendations for sending children back to classrooms.

Earlier this week, Redfield stressed the wearing of masks as a key component to any strategy for reopening schools.

"Because to me, face coverings are the key. If you really look at it, the data is really clear -- they work," Redfield said."

Is this all fake news, or poor communications.  How many layers of desks do these communications go through?

Coincidences?

White House orders hospitals to bypass CDC and send covid-19 reports directly to the White House

White House instructs CDC to not testify at House Committee.

Other information was discovered in regard to Robert Redfield

Perhaps the White House has lost confidence in Dr. Redfield as director of the CDC. While there is considerable frustration at the White House they continue to have considerable faith in Anthony Fauci M.D.  Dr. Fauci is head of the National Institute of Allergy and Infectious Diseases, a department in the NIH. Rather than depending on the head of the CDC.  Dr. Fauci was called upon to direct and consult the approach to Covid-19. Dr. Fauci remains a stellar example for scientific research and also immune to political pressures.

As the coronavirus death toll  in the US  tops 107,000, questions have intensified over what could have been done to avoid such a catastrophic loss of life.  Beyond criticism of President Donald Trump himself, scrutiny has fallen particularly hard on the US Centers for Disease Control and Prevention and its embattled director, Dr. Robert Redfield, whom Trump appointed to the job in 2018.

In interviews with numerous public health experts, including eight current CDC officials, many said they are disillusioned by Redfield, telling CNN he's failed to push back against White House efforts to sideline the CDC and politicize its science.

While sources consistently described Redfield as a respected doctor, they also view him as a relatively ineffectual public health leader at a time of the pandemic, and a pawn of the President's political agenda.

"A major problem for our agency is lack of leadership," said one CDC official who spoke about Redfield on the condition of anonymity for fear of reprisal. "He's a very nice guy, but I think he was put in place to serve a political purpose, not to lead an agency."

Inside the CDC, confidence in Redfield has deteriorated amid the rising death toll. CDC sources who spoke to CNN said they are deeply frustrated over what they say has been an effort to freeze out the agency from decision-making, and cut it off from directly addressing the public. Tensions have risen between the White House and the Atlanta-based public health agency, with some CDC officials blaming Redfield for not doing more to advocate for the agency's own authority.

This is not the first time Redfield has been at the heart of a controversy over the government's response to a virus epidemic. In the early 1990s, Redfield, then one of the Army's top AIDS researchers, was at the center of a scandal over a purported HIV vaccine. Allegations that Redfield oversold data and cherry-picked results sparked an internal Army investigation into his work. 

The Army ultimately did not charge Redfield with scientific misconduct. But interviews with former colleagues with direct knowledge of the investigation, and a review of internal documents suggest Redfield knew he was misrepresenting the data behind the vaccine, even as he publicly touted its results— an effort that ultimately helped garner millions in federal funds for further testing.

Redfield was also found to be in violation of Army code over his relationship with a conservative AIDS nonprofit run by a prominent evangelical activist who has promoted abstinence-only solutions to the disease.

In the end, the vaccine treatment did not pan out. Redfield has previously said that he stands by his work.

Manu Raju contributed to this story.

https://tinyurl.com/yx979obk

Mask Exemptions During the COVID-19 Pandemic—A New Frontier for Clinicians | Global Health | JAMA Health Forum | JAMA Network

Mask Exemptions During the COVID-19 Pandemic—A New Frontier for Clinicians

To mask, or not to mask, that is the question.   Americans obsess about their freedoms, the constitution was written to protect them.  It was originally intended to prevent despots from suppressing the possibility of overthrowing a government by allowing contrary views.  Since 1776 many have taken the liberty of using it for other purposes. Historically many individuals and groups have repurposed the amendment II to validate their argument. This is also true for many. constitutional amendments. 

What are the risks of not masking? It depends on where you are and how many other individuals are close to you.  That begs the questions, how close, and what locations?

In an article by The Journal of the American Medical Association  Doron Dorfman,LLB, JSD; Mical Raz, MD, Ph.D., MSHP write about exemptions for disability under the definition of the Americans with Disability Act (ADA).  This further confounds the answer. Dorfman and Raz make a rational if not more complex about wearing masks during a pandemic.

Masking or face covering amid the global coronavirus disease 2019 (COVID-19) pandemic has emerged as a highly polarizing practice, with surprising partisan divisions. While masking remains contentious, there is bipartisan agreement among policymakers that medical exemptions for masking are necessary and appropriate. Yet there is a dearth of guidance for clinicians on how to approach a request for an exemption. We analyze the medical and legal standards to guide this debate.

Medical Exemptions

Few guidelines exist regarding medical exemptions. Beyond the CDC’s recommended exemptions—children younger than 2 years, people with difficulty breathing, and anyone unable to place or remove the mask—there are certain categories of disability that undoubtedly warrant medical exemptions. In this evidence-free zone, clinicians must make individual determinations as to whether a patient should be exempt from mask-wearing. Some individuals, particularly children, with sensory processing disorders may be unable to tolerate masks. Facial deformities that are incompatible with masking are an additional category of exemption. Other situations, such as chronic pulmonary illnesses without an active exacerbation, are less clear. An individual with a chronic pulmonary illness is at higher risk for severe disease from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19. Conversely, if that same individual were infected with SARS-CoV-2, he or she would likely also be at higher risk for spreading viral illness because many pulmonary illnesses are associated with a chronic cough. There is a risk-benefit ratio that must be carefully considered. Professional societies would provide a valuable service to clinicians if they could provide clear guidelines that include objective measures, such as a decrease in pulse oximetry results, to guide determinations. It is likely that chronic pulmonary disease in itself is a compelling reason for masking, rather than a category of exemption.

Legal Grounds for Exemption

A medically necessary exemption from masking is considered a disability modification under the Americans With Disabilities Act (ADA). Individuals with disabilities have clearly defined legal protections under both federal and state law. Title II of the ADA prohibits disability discrimination in “programs and activities of state and local government entities.” Title III prohibits disability discrimination “in the full and equal enjoyment of…services” at places of “public accommodation.” These are privately owned establishments and include restaurants, hotels, and grocery stores, which may require customers to mask. The “full and equal enjoyment” standard can be fulfilled via the use of “reasonable modifications in policies, practices, or procedures.” A reasonable disability modification might be a masking exemption, but this is not the sole remedy. Amid a global pandemic, reasonable accommodations for masking intolerance can and should include avoidance measures, such as curbside services and delivery.3

Employers can legally require masking at their workplace, and workers may be asked to provide medical documentation for an exemption. This presents a unique challenge to clinicians who understand the necessity for individuals with disabilities to maintain job security. Yet few medical conditions are truly incompatible with all forms of mask-wearing, and the same guiding principles of preserving public health and reducing individual risk remain relevant. As other workers cannot reasonably exempt themselves from the presence of an unmasked coworker, workplace accommodations should be conceptualized in a broader framework than a simple mask exemption. These accommodations might include remote work, placement in non–public-facing positions, or, under certain conditions, leave. These may all be considered reasonable accommodations under title I of the ADA, which regulates employment.⁴

Employers restaurants and other public gathering places may utilize methods to ensure distancing.

The solutions beg creativity

Mask Exemptions During the COVID-19 Pandemic—A New Frontier for Clinicians | Global Health | JAMA Health Forum | JAMA Network

Former CDC directors: Trump has politicized science more than any past president. - The Washington Post

         

      The administration is undermining public health

                      

It fouls the mind when a politician makes decisions that are contrary to educated people. Even giving the President the benefit of the doubt he should delegate decisions such as public health decisions to those who know and have the experience to make rational decisions.

                                         

                

Public health authorities throughout the United States already have legal authority locally and at state, levels to make decisions without consulting the Executive branch.  It is the Executive Branches duty to support the states in their decisions.

In addition to those in authority, there are many qualified experts who have served previously in the CDC. such as Tom Frieden, MD, Jeffrey Koplan M.D., and David Satcher, M.D. all who served as Director of the CDC.  

Former CDC Directors Richard Besser, Tom Frieden, Jeffrey Koplan, and David Satcher explain why the agency's guidance on reopening schools must be based on sound science, not political pressure—and centered on safety and health equity.

As America begins the formidable task of getting our kids back to school and all of us back to work safely amid a pandemic that is only getting worse, public health experts face two opponents: COVID-19, but also political leaders and others attempting to undermine the Centers for Disease Control and Prevention. As the debate, last week around reopening schools more safely showed these repeated efforts to subvert sound public health guidelines introduce chaos and uncertainty while unnecessarily putting lives at risk.

As of this date, the CDC guidelines, which were designed to protect children, teachers, school staffers, and their families — no matter the state and no matter the politics — have not been altered. It is not unusual for CDC guidelines to be changed or amended during a clearance process that moves through multiple agencies and the White House. But it is extraordinary for guidelines to be undermined after their release. Through last week, and into Monday, the administration continued to cast public doubt on the agency’s recommendations and role in informing and guiding the nation’s pandemic response. On Sunday, Education Secretary Betsy DeVos characterized the CDC guidelines as an impediment to reopening schools quickly rather than what they are: the path to doing so safely. 

CDC updates expands list of people at risk of severe COVID-19 illness only valid reason to change released guidelines is new information and new science — not politics.

Older Adults.                         People of any age with these conditions

The latest from the CDC (video)

COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU)

The CDC is home to thousands of experts who for decades have fought deadly pathogens such as HIV, Zika, and Ebola. Despite the inevitable challenges of evolving science and the public’s expectation of certainty, these are the people best positioned to help our country emerge from this crisis as safely as possible. Unfortunately, their sound science is being challenged with partisan potshots, sowing confusion and mistrust at a time when the American people need leadership, expertise, and clarity. These efforts have even fueled a backlash against public health officials across the country: Public servants have been harassed, threatened, and forced to resign when we need them most. This is unconscionable and dangerous.

We’re seeing the terrible effect of undermining the CDC play out in our population. Willful disregard for public health guidelines is, unsurprisingly, leading to a sharp rise in infections and deaths. America now stands as a global outlier in the coronavirus pandemic. This tragic indictment of our efforts is even more egregious in light of the disproportionate impact we’ve witnessed on communities of color and lower-income essential workers. China, using the same mitigation tools available to us and with a far larger population, has had just a tiny fraction of the 3.1 million cases reported here. The United States now has more cases and deaths than any other country and the sixth-highest rate of any large country in the world — and we are gaining on the other five. The United States is home to a quarter of the world’s reported coronavirus infections and deaths, despite being home to only 4.4 percent of the global population.

Perhaps when tragedy strikes a sense of humor can confound the true gravity of a situtation. 

 

Comedy and Cartoons

Former CDC directors: Trump has politicized science more than any past president. - The Washington Post

How Coronavirus Kills Some People But Not Others - I'm a Lung Doctor (ME...

If you want to learn much more about how Covid-19 makes people so ill and how they die. Its complicated and has similar methods as other lethal diseases. Besides causing pulmonary insufficiency it causes increased coagulation in other organs such as the heart, lungs, kidneys, and brain. 









Dr. Mike Hanson is an outstanding clinician and an outstanding communicator. I highly recommend this video as a credible source.



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