Author Archives: henrykotula

Coronavirus cases soar by more than 1 million over 5 days

Posted on by • Posted in 2020 Election Issues, Asymptomatic Transmission, Coronavirus, Economic Crisis, Economy Reopening, Evidence-based Leadership, Evidence-Based Plan, Evidence-Based Policy, False Hope, False Narrative, Health Policy, Infection Control, Infection Control Plan, Infectious Virus, Leadership Decentralized, Mislead, Misleading, Mixed Message, Mortality, National Strategy, Pandemic, Partisanship, Personal Protective Equipment (PPE), Public Health, Public Safety, Quarantine, Scientists, Social Distancing, Suppressing Transmission, World Health Organization (WHO) • Leave a comment

https://www.cnn.com/2020/07/14/world/million-coronavirus-cases-five-days-intl/index.html

Coronavirus cases soar by more than 1 million over 5 days - WRCBtv ...

Coronavirus cases soared by more than a million globally in just five days as the numbers continue to accelerate from week to week, according to figures from Johns Hopkins University.

Reported cases increased by 1,046,200 from July 6 through July 10, up from a 994,400 increase over the five days from July 5 through July 9.
The total global case number surpassed 13 million on Monday, growing by 1,061,600 between July 8 and July 13.
While some countries that were hit early in the outbreak have managed to contain the virus, the number of cases globally has been accelerating fairly steadily.
There have now been more than half a million deaths from the virus worldwide, according to JHU data.
The World Health Organization’s director-general on Monday warned there would be “no return to the old normal for the foreseeable future.”
Tedros Adhanom Ghebreyesus told a media briefing in Geneva that there were no shortcuts out of this pandemic, and that while we may hope for an effective vaccine, there must be a focus on using the tools that are available now to suppress transmission and save lives.
“We need to reach a sustainable situation where we do have adequate control of this virus without shutting down our lives entirely, or lurching from lockdown to lockdown,” Tedros said.
He told reporters there was a “roadmap to a situation where we can control the disease and get on with our lives” that would require three things: a focus on reducing mortality and suppressing transmission; an “empowered, engaged community” that takes individual measures to protect the whole community; and strong government leadership and communication.
Two countries accounted for half of all new cases added worldwide on Sunday, he told the briefing.
“Yesterday, 230,000 cases of Covid-19 were reported to WHO. Almost 80% of those cases were reported from just 10 countries, and 50% come from just two countries,” he said.
Tedros did not name the countries, but WHO data indicated that he was referring to the United States and Brazil. According to the JHU tally of cases, the US, India and Brazil accounted for more than 112,000 new cases on Sunday.
The US has the world’s highest confirmed numbers, with at least 3.4 million recorded cases and at least 135,615 deaths. Brazil has almost 2 million confirmed cases and India is closing in on one million.
“Let me be blunt: Too many countries are headed in the wrong direction,” Tedros said.
“If governments do not clearly communicate with their citizens and roll out a comprehensive strategy focused on suppressing transmission and saving lives; if populations do not follow the basic principles of physical distancing, hand washing, wearing masks, there is only one way this is going to go. It’s going to get worse and worse and worse.”
“But it does not have to be this way,” he added. “It’s never too late to bring the virus under control, even if there has been explosive transmission.”

 

 

 

Finding COVID-19 Cases Among the Dead: ‘It May Help the Living’

Posted on by • Posted in 2020 Election Issues, Coronavirus, Death Certificate, Death Toll, Medical Examiner, Mortality, Public Health • Leave a comment

https://www.medpagetoday.com/infectiousdisease/covid19/87554?xid=fb_o&trw=no&fbclid=IwAR3NQMSqmtuTSGyY9tSH-erKLguf7b7qEtvKUdeFlBU8SuW8-FTtKE0OoR8

A corpse in the morgue with a COVID-19 toe tag

The number of deaths reported to the office of Connecticut’s chief medical examiner, James Gill, MD, spiked 137% in April, mostly due to COVID-19.

Now, Gill sees a handful of cases each day, but there are more nuances to his investigations, with some patients experiencing lingering COVID-19 symptoms for weeks, or even months.

Although most COVID-19 deaths are identified by frontline providers on death certificates, medical examiners investigate suspected COVID-19 cases in deaths taking place in the home or nursing homes. Their task is to determine which deaths are from versus with COVID-19 — that is, which are indeed caused by COVID-19 itself and which are caused by underlying conditions unrelated to COVID-19.

Such investigations have important implications for national policy, especially following the chaos in March and April when many hospitals could barely keep their heads above a flood of extremely sick patients, and testing capacity could not keep up. In all likelihood, some deaths were erroneously recorded as COVID-related, while others that were indeed from COVID-19 were not recorded as such.

Having an accurate picture of COVID-19’s lethality is vital as politicians determine how far to go in trying to halt the infection’s spread. Current estimates of the mortality rate vary by an order of magnitude or more, not only because the denominator (the number of infections) is unknown, but also because the numerator (actual COVID-19 deaths) is as well.

Most epidemiologists and infection disease specialists believe the official COVID-19 death toll is an undercount. But whether that’s the case, and if so, by how much, are hotly debated.

“It’s easy to make a diagnosis when the person dies in the hospital and has respiratory complications and so forth,” Gill told MedPage Today. “But some of these delayed deaths, the question is, are they dying from a complication of COVID-19 or are there underlying health problems they are dying from without any relation to COVID-19?”

And the mere presence of a positive SARS-CoV-2 test result, while necessary, is not sufficient to make a diagnosis of death from COVID-19.

 

Gray Zone

The National Vital Statistics System (NVSS) guidelines for death certification require providers to include COVID-19 on death certificates if the virus “played a role in the death,” but the extent of that role is not always clear.

Medical examiners must take into account nasopharyngeal swab results taken before or after death, but also clinical symptoms decedents had, like fever, cough, or chest pain.

“If a person just puts dementia on the death certificate, that is a common cause of death that wouldn’t trigger an investigation,” Gill said. “If they put respiratory complications or pneumonia due to dementia, then that may trigger me to look into it a little more to see if they had COVID testing in this case.”

When COVID-19 leads to lethal phenomena such as pneumonia or acute respiratory distress syndrome, COVID-19 will typically be listed as the underlying cause of death, per the guidelines.

But some deaths, such as those due to cardiovascular events, may be inconspicuously caused by COVID-19 infection, creating a diagnostic “gray zone,” said Benjamin Tolchin, MD, MS, of the Yale School of Medicine in New Haven, Connecticut.

In the beginning of the pandemic, when testing was limited and clinicians were less familiar with what the COVID-19 illness looked like, the distinction was less clear. COVID-19 can affect the heart, and can also exacerbate underlying conditions such as asthma or chronic obstructive pulmonary disease.

In determining whether the cause of death was related to COVID-19, “it may not always be possible to determine,” said Lauren Ferrante, MD, MHS, also of Yale, although she noted this is probably a minority of cases.

If a patient dies from a heart attack or arrhythmia, a provider can usually determine whether the patient had evidence of cardiomyopathy that was pre-existing or new in the setting of COVID-19, Ferrante explained.

But let’s say the patient died from heart disease and also had an asymptomatic SARS-CoV-2 infection. In that case, the heart disease would still be listed as the primary cause of death, although providers can note COVID-19 on the death certificate, forensic pathologist Judy Melinek, MD, wrote in an op-ed for MedPage Today.

The amount of information provided on death certificates is left to providers’ discretion, with some using them strictly to report the cause of death, and others including a range of other factors, said Jonathan L. Arden, MD, board chair of the National Association of Medical Examiners.

He said he operates under the former definition because, while the latter can be a data collection device to identify potential infections, it raises the possibility of falsely attributing deaths to COVID-19.

“The practitioners who signed the death certificate are not medical examiners in most jurisdictions and they may not understand that [distinction] or apply that consistently,” Arden told MedPage Today. “I worry about using death certificate data as a data collection source for non-death related factors, but some places are doing that.”

The accuracy of death certificates is important not only for family members of the deceased, but from a public health standpoint, Gill said.

“Whether they are positive or not, you want to make sure to do an investigation to get the proper cause of death, first as a responsibility towards family members who may have been exposed, but also for the public health benefit of testing the person that died,” Gill said. “It may help the living.”

Filling in the Gaps

In Connecticut, Gill and his team identified over 60 deaths attributable to COVID-19 while investigating decedents in funeral homes, he said.

One way to measure the pandemic’s comprehensive mortality rate is by comparing recent death totals to years past, providing an estimate of “excess” deaths. Although official death statistics are often delayed by a year or more, two recent studies used provisional mortality data to generate such an estimate for the pandemic.

From March 1 to May 30, “excess” deaths totalled just over 122,000 in the U.S., of which 78% had been officially attributed to COVID-19, according to a paper in JAMA Internal Medicine.

That left roughly 27,000 excess deaths potentially related to COVID-19.

Those might have been COVID-19 cases missed in traditional reporting, as well as deaths from delays in care for other conditions, said the study’s first author, Dan Weinberger, PhD, of the Yale School of Medicine.

Similar findings emerged from a separate study published in JAMA, with data from March 1 to April 25. In that paper, states with the highest rate of COVID-19 deaths also experienced large increases in deaths due to other diseases, like diabetes and heart disease, said lead author Steven H. Woolf, MD, MPH, of Virginia Commonwealth University.

“It’s important for cities and states getting overwhelmed by COVID-19 now to be prepared for those spikes,” Woolf told MedPage Today.

Those data covered the period when New York and New Jersey were experiencing peak mortality rates and testing was less widespread; thus, some deaths may have involved undiagnosed COVID-19.

“I would not be surprised if some of those increases in stroke and dementia deaths are probably COVID-19,” Gill said.

In the study by Weinberger’s group, which extended into May, “excess” deaths that had not been classed as COVID-related declined as time went on — as would be expected if diagnoses and certifications were getting better.

Although excess mortality rates “would represent an upper bound for the number of deaths that might have been missed,” they are also “the most complete accounting of the toll of the epidemic in the U.S.,” Weinberger told MedPage Today in an email.

In contrast, how health officials distinguish between deaths with versus from COVID-19 has been criticized by some on social media as a means of exaggerating the pandemic’s death toll. Republican leaders have also accused health officials of inflating the numbers.

Woolf pushed back against that sentiment.

“That’s clearly not the case,” he said. “In fact, it’s the other way around.”

 

 

 

 

Fauci has been an example of conscience and courage.

Posted on by • Posted in 2020 Election Issues, Accountability, Asymptomatic Transmission, Blame, Conviction, Core Values, Coronavirus, Courage, Credibility, Crisis, Crisis Management, Economic Crisis, Economic Recovery, Economy Reopening, Emergency Preparedness, Ethics, Evidence-Based Care, Evidence-based Leadership, Evidence-Based Plan, Evidence-Based Policy, Failure, False Hope, False Narrative, Honesty, Infection Control, Infection Control Plan, Infectious Virus, Integrity, Mislead, Misleading, Mistrust, Mixed Message, Pandemic, Pass the Buck, Personal Protective Equipment (PPE), Public Health, Public Safety, Quarantine, Scapegoat, Scientists, Social Distancing, Supply Chain, Trust, Truth, Wishful Thinking • Leave a comment

https://www.washingtonpost.com/opinions/fauci-has-been-an-example-of-conscience-and-courage-trump-has-been-nothing-but-weak/2020/07/13/7c9a7578-c52b-11ea-8ffe-372be8d82298_story.html?fbclid=IwAR0n0o67FMhhUjxqU11cfrd4daMkW0ZWZtIg–I1P3ioLPA7ka7Ew0XT_EA&utm_campaign=wp_main&utm_medium=social&utm_source=facebook

Opinion | Fauci has been an example of conscience and courage ...

When historians try to identify the most shameful documents from the Trump administration, a few are likely to stand out. For unconstitutional bigotry, it is hard to beat the initial executive order banning travel to the United States from Muslim countries. For cruelty and smallness, there is the “zero tolerance” directive to federal prosecutors that led to family separations at the border. For naked corruption, there is the transcript of the quid-pro-quo conversation between President Trump and the president of Ukraine.

But for rash, foolish irresponsibility, I’d nominate the opposition research paper recently circulated by the White House in an attempt to discredit the National Institute of Allergy and Infectious Diseases’ Anthony S. Fauci. As reported by The Post, the document recounted a number of instances — on community transmission, asymptomatic transmission and mask wearing in particular — where Fauci’s views have shifted over time. As far as I know, this official record is unique: A White House attack on the government’s leading infectious-disease specialist during a raging pandemic. It indicates an administration so far gone in rage, bitterness and paranoia that it can no longer be trusted to preserve American lives.

From a purely political standpoint, it is understandable that the administration would want to divert attention from its covid-19 record. Trump’s policy of reopening at any cost is exacting a mounting cost. Five months into the greatest health crisis of modern U.S. history, there are still serious problems with supply chains for protective equipment. There are still long wait times for testing results in many places. The contact tracing process in many communities remains (as one health expert described it to me) “a joke.” More than 132,000 Americans have died.

Rather than addressing these failures, Trump has chosen to sabotage a public official who admits their existence. Rather than confronting these problems, Trump wants to ensure his whole administration lies about them in unison. The president has surveyed America’s massive spike in new infections and thinks the most urgent matter is . . . message discipline.

It is true that a number of Fauci’s views on the novel coronavirus have evolved (though some of the administration’s charges against him are distorted). But attacking a scientist for making such shifts is to willfully misunderstand the role of science in the fight against disease. We do not trust public health officials during an emerging pandemic because they have fully formed scientific views from the beginning. We trust them because 1) they are making judgments based on the best available information and 2) they have no other motive than the health of the public. If, say, health officials were initially mistaken about the possibility of asymptomatic transmission, it is not failure when they change their views according to better data. It is the nature of the scientific method and the definition of their duty.

In the inch-deep world of politics, amending your view based on new information is a flip-flop. In epidemiology, it is known as, well, epidemiology.

Meanwhile, the president is failing according to both requirements of public trust. Trump is not making judgments based on the best available information. And he clearly has political goals that compete with (and often override) his commitment to public health. The president is hoping against hope that the public will forget about the virus until November, or at least about the federal role in fighting it. To apply a veneer of normalcy, he is holding public events that endanger his staff and his audience and is planning a Republican convention that will double as a petri dish.

It now seems likely that the most decisive moment of the American pandemic took place in mid-April when new cases began to stabilize around 25,000 a day. Even four or six more weeks of firm presidential leadership — urging the tough, sacrificial application of stay-at-home orders — might have reduced the burden of disease to more sustainable levels, as happened in Western Europe. And this would have relieved stress on systems of testing, tracing and treatment.

But Trump’s nerve failed him. Instead of holding firm, he began siding with populist demands for immediate opening, pressuring governors to take precipitous steps and encouraging skepticism about basic public health information and measures. This may well have been the defining moment of the Trump presidency. And he was weak, weak, weak.

It is typical for Trump to shift blame. But in this case, the president has selected his fall guy poorly. Fauci has been an example of conscience and courage in an administration that values neither. When Trump encourages a contrast to his own selfishness and cravenness, he only damages himself.

 

 

 

 

Does Delirium Cause Long-Term Cognitive Decline?

Posted on by • Posted in Coronavirus, Delirium, Intensive Care (ICU), Long-Term Cognitive Decline, Ventilators • Leave a comment

https://www.medpagetoday.com/neurology/dementia/87543?xid=nl_popmed_2020-07-14&eun=g885344d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=DailyUpdate_071420&utm_term=NL_Daily_Breaking_News_Active

Does Delirium Cause Long-Term Cognitive Decline? | MedPage Today

 Analysis has “great implications in the COVID era”

Delirium was linked to long-term cognitive decline in both surgical and nonsurgical patients, a meta-analysis showed.

Patients who experienced an episode of delirium were more than twice as likely to show long-term cognitive decline than patients without delirium (OR 2.30, 95% CI 1.85-2.86), reported Terry Goldberg, PhD, of Columbia University in New York City, and co-authors.

Delirium was associated with long-term cognitive decline with a Hedges g effect size of 0.45 (95% CI 0.34-0.57, P<0.001) in a meta-analysis of 23 observational studies (after one outlier study with an exceptionally high OR was excluded), they wrote in JAMA Neurology. Effect sizes were similar between surgical and nonsurgical groups.

“The connection between delirium and cognitive decline that we observed was highly significant and remarkably consistent,” Goldberg said.

“What we propose is that delirium is not simply a marker for those patients already on a downward trajectory, but may be causative in and of itself,” he told MedPage Today. “This may be especially relevant to COVID patients, many of whom experience delirium in the ICU.”

Delirium is “ubiquitous and spares no age groups or populations, occurring in 20% to 70% of hospitalized patients, with the higher numbers seen in critically ill patients on mechanical ventilation,” said Pratik Pandharipande, MD, co-director of the Critical Illness, Brain Dysfunction and Survivorship Center at Vanderbilt University in Nashville, who wasn’t involved with the meta-analysis.

“This study has great implications in the COVID era,” Pandharipande told MedPage Today. “Mechanically ventilated patients with COVID are at a much higher risk of developing delirium because they are subject to all the major risk factors — deeper levels of sedation, high severity of illness, often older age, and additionally, social isolation due to limited visitation rules in the hospital and the fact that the virus can directly affect the brain and lead to neuroinflammation.”

“The meta-analysis reported here shows a consistent message; all selected studies showed that delirium and longer duration of delirium were associated with cognitive impairment,” Pandharipande continued.

“While it is unclear if delirium causes dementia, there is mounting evidence — and the meta-analysis adds to this — that there are structural brain changes with delirium and this puts you at a worse cognitive trajectory,” he said.

“Incorporating strategies such as the ABCDEF bundle from the Society of Critical Care Medicine into the care of your patients — including mechanically ventilated COVID patients — is likely to reduce delirium and possibly its long-term consequences,” he added.

The meta-analysis included a systematic search of articles from 1965 through 2018. The researchers looked for studies that contrasted patients with and without delirium, had objective continuous or binary measures of cognitive outcome, and had a final time point of 3 months or later after the delirium episode.

Data from 24 observational studies, including 3,562 patients who experienced delirium and 6,987 controls who did not, were used. One study with an OR greater than 41 — an order of magnitude greater than any other study — was excluded from some analyses.

Mean study age was about 75 and mean follow-up after a delirium episode was 2.4 years. On average, men made up about 47% of the study populations. The Confusion Assessment Method (CAM) or CAM–intensive care unit was the most frequent delirium measure used, and the Mini-Mental State Examination was used most frequently as a cognitive outcome.

“In all studies, the group that experienced delirium had worse cognition at the final time point,” Goldberg and co-authors wrote.

Meta-regression did not show differences in cognitive outcomes between surgical and nonsurgical studies, suggesting “the underlying pathophysiological events associated with delirium may be similar and speculatively may be associated with inflammatory processes common to both contexts,” they added.

The researchers also did not find significant differences between cognition treated as a continuous variable based on neurocognitive test scores or as a binary variable based on the presence or absence of dementia.

The I2 measure of between-study variability in g was 0.81. Studies of longer duration yielded greater differences, while those with more covariates, and those without baseline cognitive matching, yielded smaller differences.

The observational studies used in this meta-analysis cannot show that delirium is a causative factor in subsequent cognitive decline, the researchers noted. Differences in cognitive outcome measures and the way dementia was diagnosed may be sources of variability, but meta-regressions did not find significant differences among them in terms of their effect on g, they added.

Importantly, the study could not evaluate delirium in the context of other factors, such as frailty, and unmeasured confounders may have influenced results.

 

 

 

 

Quest reports longer waits for test results

Posted on by • Posted in Clinical Testing, Coronavirus, Economic Crisis, Economy Reopening, Infection Control, Infection Control Plan, Infectious Virus, Pandemic, Public Health, Public Safety, Quarantine, Social Distancing • Leave a comment

https://www.axios.com/newsletters/axios-vitals-285240f4-9110-4c86-ad7e-e0c37085a957.html?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

Quest Diagnostics reports weeklong turnaround times in coronavirus ...

Quest Diagnostics said its average turnaround time for a COVID-19 test is now at “seven or more days,” up from four to five days at the end of June.

  • Its testing backlog is getting worse because of the high demand in parts of the country where infection is spreading, Axios’ Bob Herman writes.

Why it matters: Long backlogs make testing less useful — public health officials need to know what their local situation is like now, not what it was like a week ago. Delays are especially problematic if people who are infected continue to go about their lives while they wait for their results.

Between the lines: Quest told investors Monday that its second-quarter revenue will be down 6%, hovering around $1.83 billion, as coronavirus testing has supplanted other, more lucrative tests that had to be put off.

  • But Quest still expects to register a profit of at least $1.33 per share thanks to $65 million of government bailout funds and high volumes of COVID-19 tests.