Stroking Out While Black—The Complex Role of Racism | Cerebrovascular Disease | JAMA Neurology | JAMA Network

America is in the midst of a racist revolution, specifically systemic racism built into the American way of life.

Physicians have been aware of this fact for over one hundred years.  People of color have been aware of and subject to the laws of systemic racism for centuries.

Just this week the JAMA Neurology published an academic article about "Stroking Out While Black-The Complex Role of Racism."

The killing of George Floyd, an unarmed 46-year-old Black man by a White police officer in Minneapolis, led to widespread protests against police brutality. Beginning with a focus on law enforcement reforms, the protests grew in diversity and objective, evolving into a broader call to end institutionalized racism. For the first time in history, a diverse, global coalition came together to protest injustice in the societal treatment of Black lives. Perhaps it was the collision of George Floyd’s horrific death with the disproportionate and egregiously high death rates and coronavirus disease 2019 infection rates within communities of color in the US that fueled this movement. Of note, precursors of change, such as the diversity, inclusion, and equity initiatives being spawned in all major sectors (economic, education, health), hold out hope for meaningful progress. This Viewpoint highlights the complex role of racism in stroke and suggests a framework for understanding its effects.

The same may be said for the systemic disparity in health care for people of color, African American, Latino, and Native Americans.  Each group has its own issues regarding health and wellness.

Native Americans in particular are isolated often in remote areas with a paucity of health institutions, although served by the Indian Health Service.  The incidence of infectious disease, chronic illness, especially diabetes, obesity, and hypertension is much higher than in white populations.

Levels of Racism Theoretical Framework

The Levels of Racism framework delineates 3 interacting levels of racism to guide the development of interventions aimed at reducing racial differences in health outcomes.1 These include institutionalized or structural racism, personally mediated racism, and internalized racism.1 Institutionalized racism occurs when access to goods, services, and opportunities is influenced by race.1 It is also referred to as structural racism owing to its codification in organizational practice and policy, to the extent that it becomes the normative behavior—a cultural disease—without the presence of a specific transgressor. Personally mediated racism is prejudice arising from conditioned assumptions about a person’s intentions and abilities, based on race, causing implicit and explicit bias.1 Internalized racism is a by-product of structural racism and personally mediated racism, reflecting the total capitulation of the individual’s self-worth and self-esteem. It occurs when people accept racist beliefs about their own abilities and human value.1

Social Determinants of Health

Social determinants of health are the conditions in which we are born, live, learn, work, and play and their impact on our health. Differences in social determinants are linked to wealth status and drive the powerful association between a person’s zip code and life expectancy. But these conditions, operating across the socioecological spectrum of human life, are not only influenced by socioeconomic status but also by levels of racism. They include upstream factors related to health outcomes, such as housing conditions, school quality, environmental conditions, employment opportunities, access to healthy foods, and access to quality health care, all of which may be influenced by racial inequities and moderate the downstream biological processes responsible for health outcomes.

Stroke Disparities

A 2003 Institute of Medicine report,2 entitled “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” provided a compelling body of research highlighting health care injustices associated with greater mortality among Black patients. These included lower quality of health services and a lower likelihood to receive appropriate medical procedures among Black vs White US citizens.2 Poorer stroke outcomes for Black Americans compared with their White counterparts have persisted for more than 50 years. For example, Black individuals are twice as likely to die of stroke than White individuals, and this disparity is not entirely explained by differences in the prevalence of traditional risk factors (as defined by the Framingham Stroke Risk Function). Indeed, data from Reasons for Geographic and Racial Differences in Stroke (REGARDS) showed that only 40% of the Black-White incidence disparity is attributable to differences in the prevalence of traditional stroke risk factors and that the source of the outstanding 60% remains unclear.3 The REGARDS investigators suggest that this excess disparity may be driven by differences in risk factor control, the differential impact of risk factors by race and nontraditional risk factors, such as for physical inactivity, diet, and psychosocial factors, including depression and discrimination.3 Others have gone a step further by tracing stroke disparities to historical slavery, racism, and segregation.4 This active legacy of slavery manifests itself in the structural inequities of American society. They cause chronic repetitive, socially structured stressors shown to elicit physiological responses associated with cardiovascular disease and premature death. Indeed, a growing body of research regarding these physical consequences of social inequality referred to as the “weathering hypothesis,” shows that its physiological responses can be measured using markers of allostatic load.

Structural Racism and Stroke

Social determinants of health are riddled with race-based inequity due to the role of racial discrimination in resource allocation that have lingered since the US government’s redlining policies. These inequities are not only remnants of slavery and de jure segregation, but also related to the widespread de facto segregation in the US today. Evidence from US Census data suggests that, while the US has become more diverse, segregation has not appreciably improved since the era of Jim Crow. The separate social worlds between Black and White individuals are driven in part by income, preference, the absence of integrated experiences to help break the cycle of preference, and discriminatory practices, such as racial steering in which real estate brokers “steer” prospective homebuyers toward or away from certain neighborhoods based on their race. Consequently, Black individuals are concentrated in neighborhoods excluded from mainstream resources. It is why the variability of school quality across neighborhoods correlates with their racial composition. Such area deprivation, captured by economic, educational, and other environmental inequalities, is associated with worse mortality. Although beyond the purview of neurologists, these conditions may be drivers of stroke risk factors, such as smoking, obesity, hypertension, and type 2 diabetes.

Personally Mediated Racism and Stroke

This form of racism influences the decision-making of policymakers and members of governing bodies responsible for resource development and allocation, contributing to structural racism and its indirect effects on health. But personally mediated racism is also directly toxic to the health of those who experience it. It can be captured and quantified by validated scales, such as the Everyday Discrimination Scale,6 a measure of subjective experiences of discrimination. Examples of daily race-based indignities are itemized on this measure and range from microaggressions (eg, being treated as if you may be dishonest or as if people may be afraid of you, or receiving poorer service than others) to profiling and police brutality. While many of the experiences described in the measure appear minor, their sheer volume and chronicity have harmful consequences, including hypertension, higher levels of inflammation, and premature mortality.6 Moreover, even the recall of these experiences, a feature of rumination, produces adverse blood pressure responses comparable with those that occurred when the person was exposed.7

Internalized Racism and Stroke

Internalized racism and the resulting self-devaluation, self-rejection, engagement in risky health practices, and hopelessness1 has been linked to nontraditional stroke risk factors. These include depression, anxiety disorders, and several maladaptive behaviors in addition to cardiovascular disease.

The hydra-headed disadvantage of being deprived and a Black individual supports the need to include racism as a distinct construct of health disparities. Beyond social determinants of health, the insidious and paroxysmal health effects of racism directed at Black people, and which begins early in life, maybe underestimated, potentially explaining some of the excess Black-White stroke disparities observed. We call for increased funding and research that expands the use of an “equity lens” in the design and evaluation of stroke interventions and the role of racism in stroke outcomes. Promising areas of study include an examination of racism’s vascular effects on stroke risk and on differences in blood pressure control.

Stroking Out While Black—The Complex Role of Racism | Cerebrovascular Disease | JAMA Neurology | JAMA Network

Employers expect to boost virtual care offerings, survey finds | Healthcare Dive

Large employers expect to pay more than $15,500 per employee for health coverage next year, 5.3% higher than the $14,769 expected this year, according to an annual survey from nonprofit Business Group on Health. That's slightly up from the 5% increase employers estimated in each of the previous five years. 

Employers are increasingly welcoming virtual care options. About 80% of respondents said they believe telehealth will play a significant role in how care is delivered in the future, compared with 64% in 2019 and 52% in 2018. More than half said they will offer more virtual care to employees next year.

Employers also plan to expand access to virtual mental health and emotional well-being services. More than 90% said they will offer telemental health services, and 54% plan to lower or waive those costs in 2021.

Insight:

Six months into the pandemic, insurance companies are reporting record profits as Americans continue delaying routine in-person care. Many have turned to telehealth services or stopped receiving preventive and elective care altogether, making the exact cost employers will pay for workers' health coverage "a moving target" over the next few years, Ellen Kelsay, president, and CEO of the group said.

While the increased costs of treating pandemic patients, the. the pandemic caused patients to defer routine care, or even see their physician for possibly serious conditions, such as chest pain. After the acute wave of. coronavirus emergency visits, emergency rooms became empty. Patients are still wary of hospitals and doctors' offices.

Patient-provider encounter trends have stabilized, but remain significantly lower than before COVID-19

In-person doctor visits plummeted during the start of the COVID-19 crisis in the United States, but have rebounded to a rate somewhat below pre-pandemic levels, according to a new analysis issued by The Commonwealth Fund and conducted by researchers from Harvard Medical School, Harvard University and the life sciences firm Phreesia.

According to data compiled through Aug. 1, all physician visits were down 9% from pre-pandemic levels. That's significantly improved compared to data from late March when visits were down 58%. Although the rebound got major traction beginning in late April, it began plateauing in early June, when all visits were 13% lower than normal. As of early August, in-person visits were down 16% compared to pre-COVID levels. States that are currently coronavirus hot spots are seeing bigger declines than states where the case levels are lower.

Meanwhile, telemedicine encounters have settled in at rates much higher than pre-pandemic levels. However, they still make up just a fraction of patient-provider encounters for care. As of the start of this month, they comprised 7.8% of all such encounters. That's compared to a peak of 13.8% in the latter part of April. Prior to COVID-19, they were only 0.1% of all visits.

On another note:

The use of telehealth services has skyrocketed since the Trump administration broke down regulatory barriers to access early into the pandemic.

In the week ended March 7, only 11,000 elderly and disabled Americans in Medicare used telehealth. By the week ended April 25, that had snowballed to 1.7 million Medicare beneficiaries.

But providers who invested heavily in those services and the companies that furnish them are dependent on those regulations to make or break future use.

AHA said it was pleased with President Donald Trump's Aug. 3 executive order to improve telehealth access in rural communities through a new payment model for rural hospitals and accountable care organizations that will use upfront and capitated payments.

And while CMS' 2021 physician fee schedule draft also released earlier this month offers additional telehealth flexibilities, it's still not enough to ensure continued virtual care access, according to the hospital lobby.

CMS' proposal notably excluded payment for audio-only telehealth visits, which AHA strongly recommends it provide.

AHA also recommends allowing annual beneficiary consent to virtual treatment to be obtained at the same time, not necessarily before, services are provided. Hospitals should retain the ability to capture diagnoses impacting risk adjustment scores through telehealth visits too, according to AHA.

The 2021 PFS proposal does include the permanent addition of nine new telehealth codes, and 13 will be covered through the calendar year in which the public health emergency ends, to give physicians a chance to deliver services virtually before CMS decides whether to permanently allow them.

Other proposed changes from CMS include allowing Medicare providers to conduct evaluation and management home visits for established patients virtually, allow an emergency room E/M virtual visit for minor to moderately severe health issues and expand some telehealth services similar to those already covered by Medicare, like for group psychotherapy or care for patients with cognitive impairment.

The administration has viewed telehealth favorably, launching a pledge to "Embrace Technology to Advance America’s Health" on Wednesday in an effort to "reassure patients, providers, and payers that telehealth is here to stay and will be covered over the long term."

The pledge calls on commercial insurers to commit to expanding flexible and affordable telehealth options, and on providers to accelerate the adoption of telehealth services, though it's still unclear exactly how far CMS will go to help facilitate those expansions long-term.

Employers expect to boost virtual care offerings, survey finds | Healthcare Dive

US FDA announces emergency authorization for convalescent plasma to treat Covid-19

The FDA said more than 70,000 patients had been treated convalescent plasma, made using the blood of people who have recovered from coronavirus infections.  

On Sunday, a source who is close to the White House Coronavirus Task Force told CNN the FDA had reviewed additional data to inform its impending EUA decision. This official has not personally reviewed the data. They added the FDA is under no obligation to consult anyone outside the agency about its decision.  (they are the buck stops here agency for pharmaceuticals, and their protocols are rigid and sacrosanct) More about that later in one of my next blogs.

Researchers hope this old-fashioned treatment will work for coronavirus.  Convalescent plasma is taken from the blood of people who have recovered from Covid-19. At the end of March, the FDA set up a pathway for scientists to try convalescent plasma with patients and study its impact. It has already been used to treat more than 60,000 Covid-19 patients. However, like blood, convalescent plasma is in limited supply and must come from donors. And while there are promising signals from some studies, there is not yet randomized clinical trial data on convalescent plasma to treat Covid-19. Some of those trials are underway.

Impact of an EUA

The New York Times reported last week an FDA emergency use authorization for blood plasma to treat Covid-19 was on hold after NIH officials intervened. The hold came after a group of federal health officials -- including National Institutes of Health Director Dr. Francis Collins, National Institute of Allergy and Infectious Diseases Director Dr. Anthony Fauci and Dr. H. Clifford Lane, NIAID deputy director -- stepped in to argue the emerging data on the treatment was too weak, the Times reported Wednesday, citing two senior administration sources.

n response to CNN, Dr. Anand Shah, FDA's deputy commissioner for medical and scientific affairs, said he couldn't comment but suggested the NIH was out of line.

"In general, NIH is not involved in the decision-making process at the FDA and does not have the entirety of confidential data the FDA uses to make these regulatory decisions," Shah said in a statement sent to CNN.

"We take seriously our mandate to follow the data and science on the review of medical products to prevent or treat COVID-19 based on the agency's established legal and regulatory standards," Shah added, saying the FDA appreciated the work of NIH and would collaborate with its sister agency.

A senior administration official told CNN's Jim Acosta on Sunday the expected emergency use authorization announcement is an important development.

Comment:  It is surprising. that FDA would make a decision without statistics from the CDC and Anthony Fauci M.D. who heads up the  Coronavirus task force. The reporting is most likely inaccurate.

Attacks on Public Health Officials During COVID-19 |

The unimaginable seems to be spreading almost as fast at Covid-19.  Public health officials have reported death threats to themselves and/or their families

(On June 24, 2020, California Governor Gavin Newsom remarked on a disturbing phenomenon: health officers are “getting attacked, getting death threats, they’re being demeaned and demoralized.”1 At least 27 health officers in 13 states (including Nichole Quick of Orange County in southern California, Ohio Health Director Amy Acton, and West Virginia Health Officer Cathy Slemp) have resigned or been fired since the start of the coronavirus disease 2019 (COVID-19) pandemic. Across the US, health officers have been subject to doxing (publishing private information to facilitate harassment), angry and armed protesters at their personal residences, vandalism, and harassing telephone calls and social media posts, some threatening bodily harm and necessitating private security details.1) 

The present harassment of health officials for proposing or taking steps to protect communities from COVID-19 is extraordinary in its scope and nature, use of social media, and danger to the ongoing pandemic response. It reflects a misunderstanding of the pandemic, biases in human risk perception, and a general decline in public civility. Some of these cases resist easy fixes, but elected officials and health officials can take certain actions to help address the problem.

Today’s increasingly routine harassment and threats against health officials have much in common with growing resistance to childhood vaccination. Since the 2015 measles outbreak that focused attention on vaccine policy, individuals opposed to vaccination mandates have attacked health officials and legislators online or in-person in Oregon, Washington, New York, New Jersey, and Colorado. For example, in 2019, protesters threw blood onto California legislators from the Senate gallery; State Senator Richard Pan received death threats and was physically assaulted. Some of the same groups, joined by other individuals frustrated with public health officials, are now actively resisting efforts to require masks, reinstitute business closures, and prepare for COVID-19 vaccination, jeopardizing the eventual acceptance of vaccines.2

What explains the unprecedented hostility to public health officials during COVID-19? Although acceptance of public health orders for COVID-19 is often framed as a “red vs blue” issue, even libertarians accept that liberty may be curtailed when its exercise harms others. However, people’s ability to perceive such harm can be undermined by decisional biases known to affect human thinking.3 Omission bias creates a preference for risks associated with doing nothing (ie, letting the virus spread) over those linked to affirmative acts, such as public health orders. Distance bias and optimism bias may be operating for those who believe COVID-19 will not seriously affect them or their loved ones. In an information space flooded with conflicting information, confirmation bias allows some people to dismiss evidence that does not comport with their preexisting beliefs.

Today I attended a meeting online with Sanjay Gupta MD (CNN correspondent) and Anthony Fauci M.D. a member of the Task Force Coordinators for the White House.  He mentioned that he hired security consultants to assure the safety of his family.  Fauci has been working 20 hour days for several months. He does not seem unusually stressed by events looking youthful and bright-eyed despite his birthdays.  He is three years older than I am and looks ten years younger. Sanjay Gupta asked how he does it.  Fauci replied it was due to the extensive every other night and weekend routines of internship and residency back in the day before regulations were put in place to prevent such "abuse" claimed by today's trainees.  Fauci seemed non-plussed about current events, perplexed about today's attitudes about government and scientists. Sanjay Gupta seemed worried and asked if he (Fauci) had a succession plan for his eventual exit from NIH, he went on to say as long as he was at the top of his game, there were no plans to exit the NIH, adding his wife would guide him when to pack it in.  

Fauci has no danger of being fired having been selected and appointed by a committee of peers at NIH and national scientific experts. Trump no longer asks Fauci nor Dr. Birx to appear with him to bolster his weak positions.

Despite the pandemic I know we would be much worse off had Fauci not been present. It is all relative, we have to work with what we have, and have no wishful thinking, we should have done this or that.   The present situation is like the perfect storm a collision of events that we must ride out to survive.  The present political division adds fuel to the storm.  The captain of the ship is indisposed, and the executive officers must take over.  We do have very competent experts in many departments, and loyalties to the captain aside intelligent people must ignore bad commands.  That is a major problem as well as conflicting orders from governors, mayors, and other local representatives. 

Fauci's plans include the rapid timely delivery of test logistics and vaccines. Although he indicated he hopes he will not be around for the next pandemic he assured us all that there would be another pandemic as sure as this one was predicted.  He emphasized the importance of lessons learned and investing in technology, and logistics to be ready for the next one.





Attacks on Public Health Officials During COVID-19 | Infectious Diseases | JAMA | JAMA Network

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

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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

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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.

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